Roosevelt Warm Springs Rehabilitation and Specialty Hospitals

Transcription

1 Roosevelt Warm Springs Rehabilitation and Specialty Hospitals Community Health Needs Assessment June 2016

2 TABLE OF CONTENTS 1. Introduction 3 2. Background Organization Structure and History CHNA team Service Area Analysis and Current Project Methods Analysis of Findings Project(s) Design and Goals Appendix 21 Page 2

3 1. INTRODUCTION As part of the Patient Protection and Affordable Care Act ruling in 2012, all hospitals are required to complete a Community Health Needs Assessment (CHNA) every three years. This is the first CHNA report completed by Roosevelt Warm Springs Rehabilitation and Specialty Hospitals. During the last three years, however, Roosevelt Warm Springs came under the leadership of Augusta University after being formerly owned and operated by the State of Georgia. With collaboration with Augusta University a leader in neurological and stroke care - and through its Joint Commission Accredited Stroke Program, the focus of the 2016 Community Health Needs Assessment project for Roosevelt Warm Springs will be stroke care. 2. BACKGROUND 2.1 Organization Structure and History Started in 1927 by Franklin Delano Roosevelt as a place of healing and rehabilitation for those with polio, Roosevelt Warm Springs Rehabilitation and Specialty Hospitals has expanded its mission to serve as a comprehensive rehabilitation center dedicated to service, technological advancement, program diversity and continuing education on behalf of persons with disabilities. Additionally, it now serves as the umbrella for two hospitals: Roosevelt Warm Springs Rehabilitation Hospital and Roosevelt Warm Springs Long Term Acute Care Hospital. In 2014, Roosevelt Warm Springs Rehabilitation and Specialty Hospitals became an extension of the Augusta University Health System. AU Health, which is located in Augusta, Georgia, is part of a consolidated university comprised of liberal arts and medical education as well as patient care. This not-for-profit enterprise has a nearly 200-year history of providing health professionals to both Georgia and nationally, and is known for health-related activities and contributions of its faculty, staff, and students to the uninsured and under-insured members of the community. Augusta University strives to be a top-tier university with a mission of providing leadership and excellence in teaching, discovery, clinical care, and service as a student-centered research university and academic health center. Augusta University embodies the application of research, education, and service to enhance the health of the community, producing tangible and measureable results. The Augusta University Health System has both nationally and internationally recognized programs in areas such as neurological conditions and stroke, and it has been on the cutting edge of research in such areas as cancer, women s health, and preventative care. With the combined efforts of AUHealth and of Roosevelt Warm Springs Rehabilitation and Specialty Hospitals, the mission of Roosevelt Warm Springs hospitals has expanded to provide intensive rehabilitation services in a caring, compassionate atmosphere through the Joint Commission Accredited Hospital. Roosevelt Warm Springs Rehabilitation Hospital accepts patients referred from acute care hospitals from all over the state of Georgia and surrounding states. Patients participate in a very structured program that includes building strength, endurance, and self-care while having medical issues managed all to prepare patients to return home and resume their lives. Focus is on early intervention for conditions affecting mobility, Page 3

4 activities of daily living, and swallowing and cognitive abilities. Part of the day is devoted to follow-up medical care addressing ongoing medical issues, and part of the day involves therapy to help the patient build up strength and skills. Psychological support is also offered, as physical trauma can be emotionally draining. Each patient is served by an interdisciplinary team lead by a physician specially trained in physical medicine and rehabilitation. The physician provides intensive medical and physical management with the registered nurses and therapists for rehabilitation providing 24 hour care. Each patient s treatment program is individualized and modified according to the progress made toward discharge goals. Other members of the team who work closely to coordinate the patient s specific treatment include: Physical Therapy, Occupational Therapist, Speech Language Pathologist, Psychologist, Respiratory Therapist, Registered Dietician, RN Case Manager/Discharge Planner, and Pharmacist. Additionally, families and primary caregivers are very important members of the team and are encouraged to interact with the team, ask questions, and attend education sessions. As Roosevelt Warm Springs includes two hospitals with specialized populations, a community resource assessment was not created. However, Roosevelt Warm Springs is itself a community resource through staff commitment and participation in programs such as the March of Dimes campaign, community health education efforts by Nurse Navigators, and leadership participation in community talks about Roosevelt Warm Springs and bringing awareness to conditions served there. 2.2 The 2016 Augusta University Community Health Needs Assessment Team The 2016 CHNA team is made of members of the Augusta University s Institutional Research division and leadership and staff within both Roosevelt Warm Springs Rehabilitation and Specialty Hospitals. Additional guidance and decision making was made by members of the Augusta University s health system executive leadership team. 2.3 Service Area Roosevelt Warm Springs Rehabilitation and Specialty Hospitals is located in the city of Warm Springs, Georgia in Meriwether County, which is in mid-western section of the state. The scope of both the LTAC and the rehabilitation hospitals services are very specialized, and they accept patients from other Georgia hospitals and surrounding states, though over 99% patients are referred from Georgia facilities (see Tables 1 and 2 for admissions by referral hospital and Figure 1 for a heat map of overall referral volumes by hospital location), and almost 95% of the patients have a home address in Georgia. Therefore, the state of Georgia has been identified as the market and service area on which to focus. Page 4

5 Table 1: Roosevelt Warm Springs Rehabilitation Hospital Admission Volumes by Top 10 Referring Hospitals, 215 Hospital Location Admission #s % of Total Admissions St. Francis Hospital Columbus, GA West GA Health System LaGrange, GA Midtown Medical Center Columbus, GA Piedmont Newnan Hospital Newnan, GA Upson Regional Medical Center Thomaston, GA Augusta University Augusta, GA 18 5 Roosevelt Warm Springs LTAC Warm Springs, GA Grady Health System Atlanta, GA Emory University Hospital Atlanta, GA Spalding Regional Hospital Griffin, GA Table 2: Roosevelt Warm Springs Long Term Acute Care Hospital Admission Volumes by Top 10 Referring Hospitals Hospital Location Admission #s % of Total Admissions West GA Health System LaGrange, GA Piedmont Newnan Hospital Newnan, GA St. Francis Hospital Columbus, GA Piedmont Fayette Hospital Fayetteville, GA Augusta University Augusta GA Piedmont Atlanta Hospital Atlanta, GA Upson Regional Medical Center Thomaston, GA Atlanta Medical Center Atlanta, GA Spalding Regional Hospital Griffin, GA Midtown Medical Center Columbus, GA Figure 1: Overall Referral Volumes by Hospital Location Figure 2: Overall Admissions Volumes by Hospital Location Page 5

6 3. ANALYSIS AND CURRENT PROJECT 3.1 Methods This Community Health Needs Assessment utilized both primary and secondary data as well as Board recommendations to determine the focus for the project. As part of the secondary data analysis, data from the Census Bureau s 2014 American Community Survey was used to determine the overall population trends of Georgia as well as the demographic (e.g., race, gender, age) and socioeconomic (e.g., poverty levels, education) make-up of the state and nation. A comparative trend analysis was made for Georgia against data for the United States. In order to begin narrowing down the potential scope of the CHNA and of the project(s) to be incorporated, the top conditions seen in Georgia were determined and reviewed using recent data from the CDC, Census Bureau, Healthy People, Robert Wood Johnson Foundation, Health Communities, state led health agencies, and the Agency for Health Research and Quality (AHRQ). Each of these organizations have either synthesized available local and national health data or have conducted large scale surveys of individuals about health conditions, access, and behaviors. After the initial list of top conditions seen in Georgia were created and secondary data gathered, information was compared with Roosevelt Warm Springs primary data provided by the hospital to the Georgia Hospital Association Discharge Dataset see what conditions were seen most often in comparison to the state data. 3.2 Analysis of Findings Analysis of Findings Secondary Data 3.2.1a Population Analysis The prevalence and severity of disease states within a community depends on several factors, including the demographics of the population. The differences in population groups require different types and approaches to health care and inform the resulting project for this needs assessment. Population Demographics Georgia and the United States also both follow the pattern of a predominantly female population at slightly more than 50% (see Table 3). Table 3: Gender Breakdown for Georgia and the United States of America Georgia USA Females 5,069,761 (51.2%) 159,591,925 (50.8%) Males 4,837,995 (48.8%) 154,515,159 (49.2%) Source: American Community Survey, Census Bureau, 2014 Page 6

7 When looking at race, nationally, the population is predominately white (n = 197,159,492; 63.9%), and this is also the case for Georgia (n = 5,448,717; 56.2%). (Figure 3). However, for Georgia, Black or African American follows closely in population totals and together they make up just over 85% of Georgians. Since the Black or African American race has a higher predisposition for several chronic conditions, including diabetes, certain cancers, and stroke, this means that Georgia as a whole tends to be at a higher risk not only culturally but also through demographics. Figure 3: Georgia and the United States Racial Breakdowns, 2014 Georgia Other Race Mixed Race Hispanic Asian Black/African American White 42, , , ,506 3,014,233 5,448,717 United States Other Race Mixed Race Hispanic Asian Black/African American White 3,187,804 6,692,885 53,070,096 15,536,209 38,460, ,159,492 Source: American Community Survey, Census Bureau, 2014 The overall age breakdown for Georgia shows that 28% of the population are under 19 and 28% are between the ages of 35 and 54. Only 11.5% of the population are elderly adults aged 65 and older (Figure 4). Page 7

8 Figure 4: Georgia Age Breakdown, years, 11% 65 and older, 12% 19 and Under, 28% years, 28% years, 21% Source: American Community Survey, Census Bureau, b Social and Economic Determinants of Health Income, Poverty, and Education Within the United States, Georgia is considered rural and lower income state with approximately 18% of its population living in poverty. Within the U.S., Georgia ranks #33 out of 50 based on median household incomes from the 2014 Census Bureau s American Community Survey results (see Table 4 for Georgia and South Carolina numbers). Table 4: Comparison of Poverty and Income between Georgia and USA, 2014 Georgia USA % Living in Poverty 18.3% 11.5% Avg. Median Household Income $49,342 $53,482 Source: Census Bureau s American Community Survey, 2014 When looking at lack of education, approximately 15% of Georgians aged 25 and older have less than a high school education, which is higher than the 13.7% in the United States as a whole. Access to Care (rural pops, HPSAs/MUAs) One aspect of access to care is being able to pay for the medical care through using some form of health insurance. However, despite the Affordable Care Act initiatives that began in 2012, 17.9% of Georgians were still without health insurance in 2014 (see Table 5 for health insurance population numbers by employment status). Page 8

9 Table 5: Comparison of Health Insurance Status for Adults Georgia USA Overall Private Insurance 6,067, ,328,517 Public Insurance (i.e., 2,770,353 96,075,708 Medicaid, Medicare) No Health Insurance 1,776,980 43,878,131 Employed No Health Insurance 867,923 22,938,045 Unemployed No Health Insurance 265,855 5,904,238 Not in the Labor Force No Health Insurance 406,508 15,462,307 Source: Census Bureau s American Community Survey, 2014 This rate of uninsured increases when looking at those that are 65 years and older. When reported in 2013, over 75% of Georgia counties in 2013 had uninsured rates of 18.6% or higher for older and elderly adults (Figure 5). Figure 5: Percent of Adults 65+ without Insurance, CDC, 2013 In addition to also a fifth of the population being uninsured, much of Georgia is rural and medically underserved. Out of 159 in Georgia, 150 either are fully designated as a medical underserved area or have parts within the county that Page 9

10 are. Likewise, all Georgia counties have at least one area that is considered a Health Professional Shortage Area c State and National Disease State Comparisons Data was compiled from multiple sources, including national survey results, Healthy People 2020, and state data. This data was then compared against services available and types of patients seen at Roosevelt Warms Springs Rehabilitation and Specialty Hospitals to narrow the focus of the state and national comparisons for some of those conditions. Heart and Vascular Disease Heart and vascular diseases are also among the more prevalent chronic conditions in the United States with nearly a third of the population having been diagnosed with one or more of the conditions, which include heart disease, hyperlipidemia, and hypertension. For all of the conditions, the prevalence rates remain higher in Georgia when compared against the rates in the United States. (Table 6) Table 6: Prevalence Rates of Heart and Vascular Diseases in Georgia and the United States, 2013 Georgia USA Hyperlipidemia Prevalence* 34.4% 33.6% Hypertension Prevalence* 34.6% 29.9% # of Hospitalizations from heart attacks 26,500** 323,292* Source: *CDC BFRSS, 2013 data **Georgia Hospital Association Discharge Dataset, DRG , calendar year 2013 As with many of the other chronic conditions, overall death rates from the disease remain concentrated within the Southeastern portion of the United States (Figure 6). Figure 6: Death Rates per 100,000 from All Heart Disease, , Age 35+ Source: CDC Interactive Atlas of Heart Disease and Stroke, Page 10

11 Within Georgia, high rates of heart disease related death are more prevalent in the more rural sections of the state, including Meriwether County where Roosevelt Warm Springs Rehabilitation Hospital is located (Figure 7). Figure 7: Rate of Heart Disease Death in Georgia, 2013 Source: CDC Interactive Maps According to Georgia s OASIS database, while death due to other Major Cardiovascular Diseases is on a downward trend (n = 16,150 in 2005 to n = 15,945 in 2014; -1.3% change), Hyperlipidemia and Hypertension are both steadily increasing (Figure 6). Figure 6: Number of Deaths due to Hyperlipidemia and Hypertension in Georgia, CY2005 CY2006 CY2007 CY2008 CY2009 CY2010 CY2011 CY2012 CY2013 CY2014 Hyperlipidemia Hypertension Source: Georgia s OASIS database Page 11

12 Stroke According to the American Stroke Association, stroke is the 5 th cause of death and the leading cause of adult disability in the United States. While Healthy People 2020 does not have any goals specific to stroke, as with all other disease related topic areas there is a desired decrease in the mortality rate from strokes. Georgia as a whole tends to appear on the higher end of the stroke mortality spectrum as it is located in the buckle of the southeastern Stroke Belt. This Stroke Belt, according to the Centers for Disease Control (CDC), is where the incidence and mortality from stroke is the highest in the United States (Figure 8 for map of stroke death rates from the CDC). Looking at the mortality statistics from the CDC, Georgia s mortality rate ranks at out of a 100,000 for those 35 and older, and the rate of hospitalization from stroke for residents 65+ ranges from 8.5 per 1,000 Medicare beneficiaries to 17.8 out of 1,000 for all Georgia. Figure 8: Stroke Death Rates, 2011 to 2013, Adults Aged 35+, by County (Source: CDC) Despite increased awareness of stroke prevention, the Georgia OASIS database shows an unchanging trend in the number of people who have died due to stroke from 2005 to 2014 (Figure 9). Page 12

13 Figure 9: Trend in Stroke-Related Deaths, Georgia, CY2005 CY2006 CY2007 CY2008 CY2009 CY2010 CY2011 CY2012 CY2013 CY2014 Source: Georgia OASIS database The goal of Healthy People 2020 is the reduction of mortality from diseases and chronic conditions, like stroke. In a study from the American Academy of Neurology, it has been found that stroke patients who see a neurologist while in the hospital are less likely to die during the hospital stay than stroke patients who do not (5.6% risk vs. 13.5% risk). Likewise, one-year mortality risk for stroke patients decreased by 23% for those who received neurological care. However, when filtered down to look only at Georgia with an overlay of hospitals offering neurological services, CDC s map of stroke mortality (see Figure 10) shows that the majority of Georgia counties have a death rate from stroke of at least a 74.3 per 100,000 adults aged 35 and over. Yet, despite this high mortality rate and the empirical evidence of the benefit of neurology care for stroke patients, only 48 hospitals within Georgia offer neurological specialty services, and only a handful of those also offer inpatient rehabilitation services equipped to handle this follow-up care of this population. Page 13

14 Figure 10: Map of Stroke Mortality in Georgia, , Aged 35+, by County Source: CDC Interactive Maps Respiratory Diseases Within the spectrum of respiratory diseases, both asthma and chronic obstructive pulmonary disease (COPD) have moderate prevalence in the United States and, unlike other chronic conditions, have both lower prevalence and mortality rates in Georgia in comparison to the United States rates (Table 7). Table 7: Comparison of Mortality and Prevalence Rates between Georgia and US. Georgia USA Time Period Asthma Prevalence (Adults) 8.3% 9% 2013 Asthma Mortality Rate 10.75% 10.82% 2010 COPD Deaths (over )(NVSS)(cases per 100,000) COPD Prevalence 6.4% 6.1% 2013 Source: CDC BFRSS Looking at a trend of state data from 2005 to 2014 through the state run OASIS database, while the number of individuals who have died from asthma has decreased (from 115 in 2005 to 94 in 2014), the overall numbers of deaths due to other respiratory conditions, including COPD, have increased (n = 6227 in 2005 to n = 7553 in 2014). Page 14

15 According to Healthy People 2020, more than 23 million people living in the United States have asthma ( In a trend comparison from 2001 to 2009, the CDC found that there were 2.1 million asthma related ED visits in 2009 a number that stayed fairly consistent throughout the whole trend period. Of those ED visits, more were in children and Black/African Americans (See Figure 11)(CDC, National Surveillance of Asthma: United States, ). Figure 11: Asthmas Emergency Department Visits Rates by Age, Sex, Race, Ethnicity, and Geographic Region, Source: National Surveillance of Asthma: United States, ; Figure 15. Healthy People 2020 s overall goal for respiratory diseases is to promote respiratory health through better prevention, detection, treatment, and education efforts ( Also, as with other conditions, Healthy People 2020 has specific data-driven target goals associated with the reduction of asthma associated deaths, hospitalizations, and emergency room visits (Table 8). However, these data were only available from Healthy People 2020 at the national level and not the state level, so comparisons between the service area of Georgia with Healthy People 2020 data could not be made. Despite targets to reduce negative impacts of asthma, deaths due to asthma have remained either steady or have increased for anyone under 65. For those 65 and older mortality have rates have declined, and for all age groups emergency room visits have declined. Page 15

16 Table 8: Healthy People 2020 Goals for Reduction of Asthma Related Deaths, Hospitalizations, and ED Visits Reduction of Asthma Related Deaths by Age Group Age Range % 2020 Target Change NA NA Reduction of Hospitalizations from Asthma by Age Group Age Range % 2020 Target Change null null NA* null NA* null NA* Reduction of Emergency Room Visits from Asthma by Age Group % Change 2020 Target null null null NA* null null null NA* null null null NA* Source: Healthy People 2020, *Reduction of ED visits for ages 5-64 were rolled into one group at the high level where the target was listed (8.7 for hospitalizations and 49.6 for ED Visits). However, for sake of comparison and differences in age groups, data was listed using the expanded population data for the goal. In addition to asthma, according to Healthy People 2020, while 13.6 million adults in the US have had a diagnosis of COPD, it is estimated that nearly the same amount have not been diagnosed yet ( COPD is also the 4 th leading cause of death in the United States, though it is preventable since most cases are related to cigarette use (CDC, National Center for Health Statistics, Compressed Mortality file ). As with asthma, Healthy People 2020 has set data-driven target goals for the reduction of COPD-related deaths, hospitalizations and ED visits; however, all have increased rather than decreased (Table 9). Page 16

17 Table 9: Reduction of COPD-related deaths, hospitalizations, and ED visits, age % Change 2020 Target Deaths Hospitalizations null null null ED Visits null null Source: Healthy People Primary Data Analysis 3.2.2a Roosevelt Warm Springs Rehabilitation and Specialty Hospitals Patient Data As Roosevelt Warm Springs is an umbrella for two separate hospitals rehabilitation and LTAC, both will be covered separately for internal data. Roosevelt Warm Springs Rehabilitation Hospital is a 52-bed licensed facility that sees an average census of 19 patients at one time though are staffed to accommodate 20 to 24 patients. Looking at calendar year 2015, the rehabilitation hospital had 368 admissions with the majority being seen for orthopedic (i.e., fracture of the femur, joint replacement, etc.) and stroke issues (Table 10). Table 10: Primary Conditions Seen at RWSRH, 2015 Condition Number of Patients Avg. Length of Stay Orthopedic Stroke Neurological General Rehabilitation/ Medicine SCI Brain Injury Source: Internal Discharge Data The patients in the rehabilitation hospital are primarily white (n = 181, 49.2%) and African American/Black (n = 179, 48.6%), relatively equally split between male and female (186 males and 182 females), and are primarily between the ages of 18 and 64 years (n = 235, 63.9%). There were no patients under 18 admitted to the rehabilitation hospital in Primary payment sources were split between Medicare and another source of payment (see Table 11). Table 11: Roosevelt Warm Springs Rehabilitation Hospital Admissions by Primary Payer, CY2015 Primary Payment Source Admission Volumes Medicare 141 Third Party/Commercial 84 Self Pay 1 Other 142 Page 17

18 Roosevelt Warm Springs LTAC Hospital has 32 licensed beds with an average of 13 patients at a time though are staffed for patients. Current renovations are underway to expand services that are available for 28 of the 32 beds. Services available include: ventilator weaning, respiratory distress, wound management, status post failed surgery care, and cardiac. Of those, vent weaning patients stay an average of days, whereas other conditions seen at the LTAC stay an average of 25 days. Within calendar year 2015, the LTAC had 160 admissions with the majority seen for respiratory conditions, skin ulcers, digestive disorders, and osteomyelitis. Table 12: LTAC Admissions by System Impacted or Major Condition, CY2015 System # of Admissions Pulmonary Edema 35 Ventilator Support 23 Other 18 Digestive System 12 Skin Ulcers 11 Osteomyelitis 11 Circulatory System 9 Nervous System 7 Other Skin and Subcutaneous Tissue 6 Other Infections and Septicemia 6 Other Respiratory System 5 Renal Failure 4 Other Musculoskeletal System and Connective Tissue 4 Surgery Site Infections 4 COPD 2 Burns 1 Cirrhosis 1 Diabetes 1 Within the LTAC, those admitted were primarily white (n = 119, 74.4%), male (n = 88, 55%), and are 65 years and over (n = 86, 53.8%). Most of the patients had Medicare as a primary payment source (n = 108, 67.5%). 3.3 Project(s) Design and Goals From the conditions seen at Roosevelt Warm Springs, the final consensus of focus for the Roosevelt Warm Springs Rehabilitation and Specialty Hospitals FY16 CHNA and CHNA project is stroke prevention and education. According to the National Heart, Lung, and Blood Institute, several risk factors are associated with having a stroke including other chronic conditions, smoking, family history, and demographics. While the prevalence of having a stroke is higher in younger men, the mortality rates are higher in women. African American/Black populations are also at a higher risk of stroke prevalence. As was noted by the demographic information for the service area, Georgia has a population that is approximately 30% black, 51% female, and 23% 55 and older. Looking at the trends of these demographics from the 2010 Census to 2014, the Page 18

19 population of older adults is on an upswing (8.5% from 2010 to 2014), meaning that the population that is susceptible to having strokes is also growing since the overall risk of having a stroke increases with age (NHLBI, 2015). Augusta University has a mission to be the regional leader in stroke care by providing exceptional, state-of-the-art quality and expertise in patient care; by educating our patients, community, healthcare partners and trainees in stroke prevention and treatment; and by fostering research into innovative treatments for stroke patients ( This mission for stroke care also applies to Roosevelt Warm Springs Rehabilitation and Specialty Hospitals through its affiliation with Augusta University Health System. A large step towards this mission is that the Roosevelt Warm Springs Rehabilitation Hospital is a Joint Commission certified stroke program. While patients are accepted at Warms Springs from all over Georgia and surrounding areas, patients who have had a stroke, whatever the severity, and need inpatient rehabilitation are referred from AU Health to Warm Springs for an individualized treatment. Services offered to stroke patients at Warm Springs include dysphagia studies and therapy, Physical Therapy, Occupational Therapy, Speech Therapy, Nutritional Therapy, Anticoagulant Management, Patient Education, Nursing, Psychology and Physician Specialty Consults when needed. Patients families are encouraged to take an active role in the patient s rehabilitation during the stay at Warm Springs, as strokes impact not just the patient but the family as well. To further this mission and commitment to stroke-related patient- and family-centered care, Roosevelt Warm Springs Rehabilitation and Specialty Hospitals will conduct a project that includes the prevention of primary strokes and recurring strokes and the education in how to live with the effects of stroke. Through these implemented goals, we hope to make the patient and their family advocates for stroke education and prevention in their community. Overall outcomes of the project will be gathered and a project dashboard will be created with the help of the Institutional Research unit of Augusta University in order to assess the success of the project and its pieces. In particular, trends and volumes will be analyzed of getting patients back home in the community versus transitioning into a nursing home care environment and stroke reoccurrence. Table 13 shows the current baseline numbers for where stroke patients were discharged. Table 13: Stroke Patient Discharge Destination, calendar year Discharge Location Community/Home 77 (70%) 63 (72.4%) 61 (61.6%) SNF/Subacute 28 (25.5%) 14 (11.5%) 26 (26.3%) Acute Care Hospital 5 (4.5%) 10 (16.1%) 12 (12.1%) An expanded education curriculum will be created for stroke patients within the facility along with their family members. This curriculum will supplement the intensive patient therapy and family education currently provided by Roosevelt Warms Springs Rehabilitation and Specialty Hospitals. Utilizing nursing and therapy staff to provide this instruction, lessons will focus on how to cope with the deficits related to the stroke, understanding the causes of strokes, recognizing the symptoms of strokes, and lifestyle changes that they can make to prevent future strokes for current patients and primary strokes in their family members. The format for the Page 19

20 curriculum will continue to be one-on-one counseling using materials and information created by organizations such as the American Stroke Association. The education begins as soon as the patient gets to Roosevelt Warm Springs and continues throughout their stay. After implementation and several iterations of this curriculum with patients and family, plans will be made to open up stroke education classes to the community at large. In addition, to the education for patient and their family members, a new policy will be created to increase the post-discharge follow-ups with the patient and family. At discharge, patients will be given information about continued care and will be informed that they will receive check-in calls from case management. An initial call will be made to the patient s home by case management within 48 hours of discharge to ensure appropriate post hospital services have been initiated, including physician appointments made, medications obtained, and therapy started. Case management will also go through a checklist of items from the National Stroke Association (see Appendix A). Any issues that are mentioned during the calls will be handled on a case-by-case basis by case management. An additional follow-up call will be made two weeks after discharge to track patient progress, then again two weeks later to address any concerns or issues related to integration back into the community, and a final call six months after discharge (see Figure 11). Patient progress will be tracked using both the National Stroke Association checklist and notes from case management, including adherence to care regimen taking medications, seeing physicians, and continuing with outpatient and home health therapy and if there has been a readmission or additional stroke that has occurred. Figure 11: Follow-up Call Timeline Post-Discharge Call 1: 48 Hours Post Discharge Check on initiation of post-hospital services Call 2: 2 Weeks Post Discharge Track patient progress and health. Address any concerns or issues Call 3: 4 Weeks Post Discharge Track patient progress and health. Address any concerns or issues Call 4: 6 Months Post Discharge Track patient progress and health. To help give patients a sense of empowerment over the effects of stroke, a program will be established to celebrate the goals achieved by our stroke patients and will make the discharge of each patient a special graduation celebration. This graduation will be complete with a small party and certificate of completion. The certificate will serve as a reminder to the patient of the successful progress he or she has made towards stroke recovery and that continued recovery is possible. Page 20

21 Appendix A: Post-Stroke Checklist Page 21

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