The Quality of Stroke Care Doesn t Stop at Discharge. Judith F Dillon, MSN, MA, RN Kathy Morrison, MSN, RN, CNRN
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1 The Quality of Stroke Care Doesn t Stop at Discharge Judith F Dillon, MSN, MA, RN Kathy Morrison, MSN, RN, CNRN
2 Objectives Describe the development and implementation of a comprehensive outpatient stroke program. Discuss how to expand quality improvement from acute hospitalization to out-patient stroke clinic. Review outcomes, as well as successes, challenges, and lessons learned.
3 Imperative to Act Nearly two-thirds of Medicare beneficiaries discharged after ischemic stroke died or were re-hospitalized within one year Comorbidities were common HTN- 76.9% CAD- 32.5% Diabetes- 28.1% History of Atrial Fibrillation or Flutter- 23.7% Causes of rehospitalizations within one year Cerebrovascular disease- 11.4% Cardiovascular % Non-Cardiovascular- 73.7% Fonarrow G et al. Stroke. Epub Dec16, 2010
4 One Year Mortality after First Stroke age 40 and younger: 21% of men and 24% of women ages 40 69: 14% of white men, 20% of white women, 19% of black men and 19% of black women age 70 and older: 24% of white men, 27% of white women, 25% of black men and 22% of black women
5 Challenge Need to better understand causes of secondary events such as death and readmission following a stroke Need to develop post discharge care strategies aimed at minimizing these secondary complications In 2013, Patient Protection and Affordable Care Act will financially penalize hospitals for high readmission rates.
6 Continuum of Care
7 Transitional Care
8 Wagner s Model of Chronic Care Illness
9 PROTECT A coordinated stroke treatment program to prevent recurrent thromboembolic events Program Treatment Goals: 1. Antithrombotic therapy 2. Statin therapy 3. Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy 4. Thiazide diuretic therapy 5. Smoking cessation advice 6. American Heart Association diet 7. Exercise counseling 8. Stroke education Preventing Recurrence Of Thromboembolic Events through Coordinated Treatment (PROTECT) Ovbiagele et al. Neurology. October 2004
10 PROTECT RESULTS High adherence rates (80-100%) at 90 days to the medication regimen 83% of smokers were still not smoking Successes related to the prompt initiation of evidence-based, guideline-recommended care in eligible patients Ovbiagele et al. Neurology. October 2004
11 Funding $100, grant from CDC for Prevention Awarded July, 2010 for 1 year Utilization: Part-time stroke nurse Part-time data entry personnel Educational materials Office supplies Laptop U.S. SENATOR ROBERT P. CASEY, JR. FISCAL 2010 APPROPRIATIONS
12 Penn State Stroke Population 2010 Gender: 53% male, 47% female Age: 53% over age 65 Race: 92% Caucasian 4% African American 3% Hispanic 35% arrive as transfers from surrounding hospitals
13 Discharge Disposition 2010 Residence PTA: Home: 92% ECF: 8% Discharge Disposition: Home: 42% Rehab: 30% ECF: 11% LTCH: 5% Expired: 15%
14 Severity Scores 2010 Ischemic Stroke Patients Average NIHSS on Admission in 2010 Average NIHSS on Discharge in 2010 Home Rehab Skilled Nursing Facility (SNF) LTCH Score 0-4 = mild impairment 5-14= moderate impairment 15-20= moderate/severe impairment 21-42= severe stroke Death 21.6
15 Goals for Stroke Care Steps to success Monitor Stroke Recovery Reduce Recurrent Stroke Decrease Secondary Complications Promote Health Reduce Cost Continuous Quality Outcome Measures Standardize Care
16 Follow up Begins at Discharge Discharge letter Resource Guide Stroke Education Tools for self management Community resources Stroke Support Invitation Phone call for High Risk patients Clinic Follow-up Appointments
17 Project BOOST- All Patients Goal : To identify patients who have high risk of complications at discharge that may result in negative outcomes, including hospital readmissions Improve Hospital Discharge Process: Increase patient understanding Decrease Medication errors Decease stress on caregiver Decrese admission rates Decrease care cost Vision: Reduce 30 day readmissions Improve patient satisfaction Improve flow of information Identify high risk patients and target intervention Society for Hospital Medicine s Project BOOST
18 Criteria for Early Phone Calls (Discharge Bundle) Discharged home Non-elective admission in past 6 months New Coumadin 5 or more new meds Inability to teach back Absence of caregiver Poorly controlled diabetes Poorly controlled HTN Hospital Goal: Reduce Hospital Readmissions
19 Data Reports and Outcomes Modified Rankin Scale Barthel Index NIHSS Score Recurrent Events Goal Status : Mortality Antiplatelet Treatment Complications Anticoagulant Treatment Atrial Fibrillation Hypertension Body Mass Index Hyperlipidemia Waist Circumference Diabetes Carotid Artery Disease Tobacco Education Rehabilitation Compliance Bundled Score
20 Electronic Tool Best Practice Guidelines
21
22 Multidisciplinary Team Approach Providers Schedulers Discharge process Clinic Process Appointments Medical Assistants role Nurse 0.5 hr Provider 1.0 hr Data Collection Missed appointments IT reports QI reporting PDCA Data Management
23 Nurse s Role How long do MD s allow their patients to speak uninterrupted? A. 1 minute B. 2 minutes C. 90 seconds D. 23 seconds Marvel et al JAMA, 281;
24 Nurse s Role On average, when not interrupted, how long will patients spend presenting an initial concern to their MD? A. 4 minutes B. 120 seconds C. 90 seconds D. 5 minutes Langewitz et al BMJ, 325;
25 Patient Engagement Utilization of trained nurses to educate, coach, assess progress, and answer questions Enable patient self-management between visits Knowledge of signs and symptoms of stroke, when to call 911, and understanding risk factors Self monitoring of clinical parameters completed by patients at home Compliance with plan of care & discussion of solutions to non-compliance issues Risk factor modification: medications, diet, exercise, smoking cessation
26 Caregiver Support Families care for 74% of stroke survivors after discharge to home Depression prevalence: 52% Mortality risk: 63% higher Stress in family caregiver impedes rehab and is leading cause of institutionalization of stroke survivors Comprehensive Overview of Nursing & Interdisciplinary Rehabilitation Care of the Stroke Patient. Stroke
27 Provider s Role Neuro Assessment Medication Adjustments Research Opportunities Referrals Education Devices addressed Therapies Driving Depression Sexual activity
28 Resources Stroke Education Resource Guide BP tracker log $5 dollar gift cards for stop smoking F.A.S.T. Magnet Stroke magazines: Stroke Connect Stroke Smart
29 Communication Monthly staff meetings clinic staff Quarterly meetings residents Quarterly updates for stroke core team Quarterly QI meetings Individual meetings with key players Educational sessions clinic staff Team building strategies Bulletin Board Incentives
30 Follow-up 30 Day Clinic Phone Chart UTR % 19% 13% 17% % 11% 11% 21% Letter/Questionnaire sent to patients who did not come for either 30-day or 90-day clinic visit. 90 day Clinic Phone Chart UTR Letter % 26% 11% 16% % 16% 7% 28% 5% Early phone calls: 2 nd half 2011 = 11 cases 8 cases New warfarin therapy 1 case Non-compliant history 1 case New diabetes diagnosis/therapy 1 case unscheduled admission during previous 6 months
31 Compliance day: 45% were non-compliant BP checks: 23% Diet: 9% Exercise: 49% Smoking: 21% Glucometer: 2% Medications: 2% 90 day: 46% non-compliant BP checks: 25% Exercise: 44% Smoking: 22% Glucometer: 2% Medications: 2%
32 Outcomes Complications 30 day 90 day Depression Falls Pneumonia Seizures UTI Readmissions 30 day 90 day TIA 10.9% 2.7% 16% 10.8% Ischemic 6.7% 6.3% 13.1% 5.5% Lichtman, Leifheit-Limson, Jones, et al. 6.5% % 30% Predictors of Hospital Readmissions After Stroke.Stroke AHRQ. Transitions of Care April 2011.
33 Disposition 2010 PTA Discharge 30 day 90 day Home 92% 42% 70% 82% Rehab 0 30% 11% 3% ECF 8% 11% 5% 5% LTCH 0 5% 7% 3% Death/Hospice % 4% 4% Unknown % 3% 2011 PTA Discharge 30 day 90 day Home 91% 56% 69% 78% Rehab 0 24% 10% 2% ECF 9% 6% 7% 7% LTCH 0 2% 4% 1% Death/Hospice % 6% 3% Unknown % 9%
34 Rehabilitation Services 30 Days Not indicated Ischemic Strokes Completed Ongoing 58% 9% 38% 27% 23% Home-based Inpatient ECF Outpatient 12% 33%
35 Rehabilitation Services 90 Days Not Indicated Ischemic Strokes Completed Ongoing 42% 18% 26% 69% 5% 8% Home-based Inpatient ECF Outpatient 32%
36 Rehabilitation Challenges 70% of first year costs acute inpatient hospital stay The lack of long-term benefits of shortterm rehabilitation suggest that therapy should be extended to home or subacute care settings. CMS looking at WHO s ICF as framework for documenting care and determining payment across the continuum Miller, Murray, Richards et al. Comprehensive Over view of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient. Stroke Duncan, Zorowitz, Bates et al. Management of Adult Stroke Rehabilitation Care. Stroke 2005.
37 14 NIHSS Scores Ischemic strokes Admission Discharge 30 Day 90 Day
38 Modified Rankin Scores Discharge Discharge 30 day 30 day 90 day Pre Admit Pre Admit day
39 Just when we thought we had all our ducks in a row
40 Patient Satisfaction Scores Question Nursing team addressed my concerns/questions to my satisfaction. Physician team addressed my concerns/questions to my satisfaction. Very Satisfied/Satisfied Scores % 92% 96% 96% I am satisfied with the therapy I received. 94% 95% My pain was well managed. 89% 94% I was given information about my medications including the importance of taking as prescribed. I was given information about my stroke/tia, signs/symptoms, when to call 911 and risk factors. 88% 81% 91% 76%
41 Successes Electronic Tool Establishment of 30 Minute Nurse Visit Patient Education Scheduling Guidelines Standardization of Process Partnership between Inpatient & Outpatient Collaboration of Stroke Team Staff Patient Satisfaction Surveys
42 Challenges Quality Data IT Reports Patients Lost to Follow-up Clinic Staff & Provider Turnover Documentation Nursing Physician MA Quality Data
43 Lessons Learned Essentials for Success User-friendly Tool Information Technology Support Clinic Flow and Patient Data Management Nursing Leadership Staff Education Administrative Support Team Approach Communication Change is Constant
44 Next Steps Tracking patient-specific patterns Comparison of outcomes for clinic visit vs phone call follow-up mrs knowledge compliance Tracking therapy patterns/outcomes Expansion of tool/model to PCP & other specialty practices
45 We
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47 Questions
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