ESTABLISHMENT OF COMMUNITY STROKE PROGRAMS. DEVELOPMENT OF THE NORTH CAROLINA COMPREHENSIVE STROKE PROGRAM

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1 Establishment of community stroke programs depend on the solution of many interrelated problems. The development of such programs in North Carolina is explored, and the factors involved are examined. Improved patterns of care are illustrated. ESTABLISHMENT OF COMMUNITY STROKE PROGRAMS. DEVELOPMENT OF THE NORTH CAROLINA COMPREHENSIVE STROKE PROGRAM B. Lionel Truscott. M.D., Ph.D. EFFORTS to establish an effective and viable community health program face many interdependent problems: (1) increased demands for medical services, (2) a critical shortage of health manpower, (3) inadequacy of, and difficult accessibility to the health delivery system, (4) unequal distribution of health resources, and (5) lack of time available to the overburdened health workers to solve these problems independently. The practical solution to these problems was a major concern of the North Carolina Comprehensive Stroke Program in a State which ranks third in the nation in the incidence and mortality of stroke,1'2 and among the lowest in the number of health workers.3 Inequitable accessibility to the health delivery system is evidenced by certain facts: 14 of the 100 counties have no hospital, 65 have no physical therapist, and almost half of the physicians are in 6 counties which serve only 25 per cent of the population. The objective of the Comprehensive Stroke Program is to increase the opportunities for the stroke patient to receive early, high quality, and continued care through a stroke program in his community. Results of the program should be measurable and the methods to achieve the objective had to be realistic within the limits of personnel and time of the community. The major role of the Program Staff would be to design the program and develop organizational and treatment guidelines which, once completed, would be available for every community and readily adaptable to their varying resources. This time-consuming activity would prepare the local program for the next phase necessary to implementation of the program: coordination and training of existing health manpower. Successful completion of these phases should result in an effective local stroke program which makes no unrealistic demands on the medical community. The organization and treatment procedures, furthermore, would be applicable to non-stroke patients and not be limited by categorical disease. This paper considers briefly the sequence of activities, and initial evaluation of the Comprehensive Stroke Program of North Carolina which is now in its third year. A preliminary report has been published.4 Community stroke programs at present involve 22 hospitals, 8 nursing homes, and 19 public health agencies in counties with a combined population of over 915,000. The hospitals vary in size from 46 to over DECEMBER,

2 400 beds, and 88 per cent of the communities are in rural or semi-rural regions. Preparatory Phase The guidelines and materials necessary to establish a stroke program in any community, regardless of size or resources, were developed in collaboration with the staff of the North Carolina Regional Medical Program and of the North Carolina Heart Association, and in consultation with the medical centers (Bowman Gray, Duke, and the University of North Carolina), State Board of Health, and practicing physicians. Subsequently, only minor changes were necessary to adapt the program to the needs and resources of a particular community. Regionalization of health resources was achieved by cooperative arrangements with the Physical Therapy Section of the State Board of Health, and Public Health and Social Services Departments of the counties involved. With expansion of the Program, support for adjoining North Carolina counties was obtained from public health nurses of Grayson County, Virginia, and the Dundee Nursing Home in Bennettsville, South Carolina. To ensure that all materials and arrangements were ready by the target date, a time-sequential work plan was prepared according to the Program Evaluation Review Technique (PERT). This activity, aided by the staff of the North Carolina Heart Association, was a major factor in subsequent evaluation. A record was prepared of physicians and/or communities expressing interest in the program, and each community was tentatively profiled (population, hospital size, stroke mortality, number of health personnel, etc.) - Hospitalization forms, follow-up report cards, guidelines of management, and other materials were developed to aid uniform treatment and follow-up and to evaluate results Establishment of a Community Stroke Program Initial Contact The objective of the program is discussed with a responsible community physician, and all organizational, educational, consultative, and other services are reviewed. The responsibilities of the community and the estimated time expenditure by participating physicians are clearly stated. With approval of the responsible physician, the Program Staff arranges a meeting (usually within 2 weeks) with an ad hoc Local Steering Committee which represents all deliverers of health care in the community. Approval by this committee completes the groundwork for establishing the local program. Organization Phase The ad hoc Steering Committee usually becomes the permanent Local Stroke Program Committee which appoints the chairmen of the following subcommittees: 1. In-Service Education (Stroke Team) 2. Discharge Planning and Follow-up 3. Area Resources Development 4. Public Education The chairmen of these subcommittees assemble the necessary members as indicated in the organizational guidelines furnished by the Program Staff. Pre-operational Phase Basic Training Course-A four-day course is conducted for members of the Stroke Team (local physician coordinator, hospital nurse, and physical therapist, public health nurse, nursing home nurse, and part-time executive secretary). This course stresses the most recent methods of diagnosis and treatment, practical rehabilitative techniques, methods of implementing effectively the local program, and the supportive role of the Program Staff. Necessary guide- VOL. 61. NO. 12. A.J.P.H.

3 COMMUNITY STROKE PROGRAMS lines, forms, and teaching materials are furnished for use in the community. In-Service Education-In collaboration with the State Board of Health Physical Therapy Consultant of the region involved, and with medical center consultants, the Program Staff conducts two joint sessions (physicians and nurses) in each community. The original proposal to have these sessions conducted by the local physician coordinator was impractical and was abandoned. These classes on diagnosis, acute medical management, and program implementation are followed by 5-6 sessions in which rehabilitative techniques are practiced by registered nurses and physical therapists of the community. In collaboration with the nurse and physical therapist of the Program Staff, the hospital nursing staff then conducts similar practical classes for licensed practical nurses, aides, and orderlies. All in-service education is conducted in the local community hospital and includes other pertinent personnel as available: dietitians, social workers, occupational therapists, speech therapists, and corrective therapists. A major aim of in-service education is to develop a knowledgeable community team which makes more effective use of existing health manpower. Rehabilitative techniques, not requiring the time of highly skilled personnel, are also demonstrated to the patient and family during hospitalization. A result of this approach is the availability of early, frequent, and continued treatment to the patient while conserving the time of the professional personnel. Operational Phase With completion of in-service education, the local program is prepared to deliver improved stroke care with maximum efficiency due to the coordination of personnel and resources, the training and more effective use of manpower, the availability of guidelines of management, and the support of local and state public health agencies in follow-up. Early and frequent rehabilitative activities, made possible by the greater number and better use of allied health personnel, offer increased opportunities for the patient to reach his fullest potential in the earliest possible time. This also frees the nursing staff to devote more time to skilled nursing care. The limited time of the physician is critical to the design of any health program, regardless of its merits. In actual practice, the time spent by the physician throughout the entire hospitalization of his stroke patient (each physician admits a new stroke patient every 3-5 weeks in the average community hospital) is about minutes: (a) on admission he checks a prepared hospitalization form which summarizes the history and health status of the patient (severity and side of weakness, functional capacity, etc.); similar checks on discharge indicate any changes; (b) he checks a prepared stroke admission orders sheet which initiates the guidelines of management (no detailed orders are necessary), orders tests, and sets a date for the discharge planning conference (completion of the above two forms takes approximately 5 minutes); (c) he holds a discharge planning conference, whose members are notified by the nurse and local secretary and who, prior to the meeting, have completed all necessary social, economic, dietary, and other plans with the family (a responsible member of which usually attends the meeting). An efficient discharge plan can be completed in minutes in most cases. With no further expenditure of time by the physician, the patient will receive improved follow-up care by the public health agency of the community, or by the nursing home personnel (whose staff has been trained by the Program). If the patient comes from, or is transferred to another stroke program county, follow-up care is conducted by the public health agency of that community. DECEMBER,

4 Table 1-Trained personnel for stroke program Physicians: 125 Licensed Hospital nurses: 390 practical Public health nurses/ nurses: 103 aides: 314 Physical therapists: 18 Other: Every 3 months a follow-up report on the status of the patient is completed by the local secretary on the basis of information received from the public health agency. Present Status of the Program Over 915,000 people reside in the 19 counties which have operational community stroke programs; 16 counties are rural. Facilities involved include 22 hospitals (2,976 beds) and 8 nursing homes (348 skilled nursing beds). Nineteen county health agencies are involved in follow-up care of the stroke patient. Existing personnel trained: 1,005. (See Table 1.) Altered Patterns of Care Data on 122 pre-stroke program and 145 post-stroke program cohorts illustrate changes in the pattern of stroke management in participating hospitals. A few examples are noted in Table 2, especially with respect to clinical and laboratory evaluation, in-hospital treatment, organized discharge planning, and scheduled follow-up care. Measurement of health status-among the data which will be available for feedback to the community are those designed to determine the extent to which new patterns of stroke care have benefited the patient. Hospitalization and follow-up reports indicate whether there has been a significant change in the number of stroke patients developing decubiti and contractures, achieving a greater degree of independence, able to perform household chores, return to part or full-time employment, and in other ways contribute to the economy of the family and the community. This information, including 3-, 6-, and 9-month follow-up reports, is presently being retrieved on over 200 patients and will be the subject of a later publication. Length of stay and hospital cost-the 145 patients managed according to the program guidelines were discharged 2.7 days sooner and the average hospital cost was $240 less than that of prestroke program patients. While the main factors responsible for this must be analyzed on a larger number of patients, it had been anticipated in designing a program which included early and frequent treatment, family involvement, and effective discharge planning and follow-up. Table 2-Stroke management in participating hospitals Evaluation performed and recorded in chart Blood pressure 71% Type and speed of onset 70% Side, severity of weakness 59% Functional ability 46% Electrocardiogram 27% F.B.S./2 hr. p.p. sugar 39% Other (skull x-ray, etc.) 18% Treatment Stroke admission orders 7% Rehabilitation begun within 48 hrs. after admission 0% Average length of stay 24.4% Mortality within 48 hrs. 24% Discharge Planning done 49% Scheduled, follow-up care to date None Pre- Postprogram program per cent of patients 96% 88% 72% 63% 51% 63% 27% 71% 22% 21.7% 16% 61% 100 pts VOL. 61. NO. 12. A.J.P.H.

5 COMMUNITY STROKE PROGRAMS Discussion The North Carolina Regional Medical Program has established community stroke programs which are available to almost one million people who live in rural areas and who are, for the most part, economically disadvantaged. All deliverers of health care are represented, coordinated and trained to provide a continuum of care from diagnosis through follow-up; in the latter respect the local and state public health agencies have been essential to the success of the program. This team effort, and the more effective use of existing health manpower, has improved and increased the accessibility to the health delivery system. In a state with high stroke incidence and critical health manpower shortage it was imperative to make better and continued care available to the stroke patient in his community. Criteria for transfer to a neurodiagnostic center are included in the guidelines developed by the central Program Staff. A critical question is whether these improved patterns of comprehensive and continued care justify the community effort. The organized sharing of responsibilities, and the training and better use of existing personnel obviates undue expenditure of time and effort by any individual or small group of individuals. This is the consensus of health personnel participating in 22 hospitals and 9 nursing homes, some in their second year of operation. The more frequent rehabilitative efforts are made possible by the training of licensed practical nurses, aides, orderlies, and members of the patient's family. The nurse, in turn, can devote more time to providing skilled nursing care. There is no significant reluctance on the part of the physician to attend the two in-service education sessions, nor to hold a discharge planning conference (10-15 minutes) on his patient, since better in-hospital and follow-up care will be the result. Furthermore, preparation of the patient and family for transfer to home or nursing home is accomplished by the public health nurse, social services representative, and other members of the discharge planning subcommittee. The major obstacle is the understandable resistance to checking forms (5 minutes), although these initiate the guidelines of management by nurse and allied health workers and evaluates any changes in the status of the patient as a result of this treatment. With increasing experience, however, most physicians are gradually recognizing the value of this effort and in many communities additional physicians are placing their patients on the program. Finally, although we believe the measurement of health status is essential to the evaluation of any health program, improved patterns of stroke care are not dependent on obtaining these data. The increasingly important role of the community hospital has been emphasized5,6 and its potential is evident in our evaluation of established local stroke programs. The approach used by the Comprehensive Stroke Program is adaptable to any community, regardless of size and resources. Although general guidelines for community stroke programs are available,78 it has been our experience that the overburdened health workers have neither the time nor the resources to develop the detailed planning and guidelines necessary for effective implementation. These activities were completed by our staff and made available to the communities. The major expenditure of time and effort by local health personnel is in the training of existing workers preparatory to initiating the program. This educational service, provided by the North Carolina Regional Medical Program, is similar to that obtained by many communities from medical centers and visiting lec- DECEMBER,

6 turers. The critical difference in the program described in this paper is that such training involves all deliverers of health care and that efforts are coordinated to deliver improved stroke management with maximum efficiency. It should be emphasized that the continued functioning of these community stroke programs is based on the initiative and cooperation of local health resources, and not on direct funding. The parttime secretary employed by our Program maintains the hospitalization and follow-up records essential for the measurement of health status which, as noted above, has no direct bearing on the procedures established for better patient care. These data are being collected and analyzed to determine the impact of the program on the patient and the quality of survivorship, and will be the subject of a forthcoming publication. Conclusions The Comprehensive Stroke Program of North Carolina has established community stroke programs involving 22 hospitals, 9 nursing homes, and 19 public health agencies. Coordination and training of local health resources were major factors in offering early, comprehensive, and continued care to the stroke patient. Improved patterns of care are illustrated by preliminary data obtained on pre-stroke and post-stroke patient cohorts. Measurement of health status and quality of survivorship are being obtained and analyzed to evaluate the impact of the program on the patient. Addendum: Since submitting this paper for publication, data has been retrieved on over 250 pre-program and 550 post-program patients. Improved patterns of care are even more striking than in the initial phases reported in this paper. REFERENCES 1. Kuller, L., et al. Nationwide cerebrovascular disease morbidity study. Stroke, 1:86-99, Tyroler, H. A. Deaths attributed to cerebrovascular disease. North Carolina Years A preliminary report prepared for the Stroke Section of the North Carolina Regional Medical Program Research and Evaluation Division, North Carolina Regional Medical Program. First biennial report, Truscott, B. L. The Comprehensive Stroke Program of North Carolina. N.C. Med. Jour., 31:95-97, (Mar., 1970). 5. Rosinski, E. F. The community hospital as a center for training and education. JAMA 206: , (Nov., 1968). 6. Somers, A. R. The hospital and community health planning. The Pharos, 32:80-84, Guide for affiliates and chapters in stroke program. Coordinating Committee of Nationwide Stroke Program of the American Heart Association. (Aug., 1966). 8. Borhani, N. O., and Meyer, J. S. Editors. Medical basis for comprehensive community stroke programs. Joint Council's Subcommittee on Cerebrovascular Disease. N.I.H. and N.I.N.D.B., National Institutes of Health, (June, 1968). Other staff members of the Comprehensive Stroke Program are: William S. Leinbach, Assistant Director (from the N. C. Heart Association); Margaret Keller, R.N., M.P.H., Nurse Education Coordinator (Assistant Professor of Public Health Nursing, Stroke, Bowman Gray School of Medicine); and Rachel L. Nunley, L.P.T., M.A., Physical Therapy Education Coordinator (Assistant Professor, School of Allied Health Professions, East Carolina University). Dr. Truscott is Director, Comprehensive Stroke Program of North Carolina, and Professor of Neurology, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina. This program is a project of the North Carolina Regional Medical Program. This paper was submitted for publication in June, VOL. 61. NO. 12. A.J.P.H.