From the 2024 HVPA National Conference
Amelia Tenberg MSN (Johns Hopkins University), Elizabeth Zink PhD (Johns Hopkins Hospital), Mona Bahouth MD, PhD
Background:
Stroke remains a leading cause of adult disability. The transition period after acute stroke is an especially vulnerable time for patients, as there may be new physical, cognitive, or emotional changes related to stroke, newly diagnosed comorbid conditions, and safety concerns. Readmission is common after stroke for a variety of reasons including high risk for recurrent stroke, destabilization of common comorbid conditions, functional sequelae from stroke, infection, falls, or other systemic complications. While readmission rates are commonly used as a quality outcome measure, there are many modifiable domains reflected by this low value outcome.
Objective:
To provide an illustrative case of individualized interventions across the post-hospital transition period which together prevent readmission for a stroke patient participating in a high-value post-hospital transitional stroke clinic.
Methods:
The Joint Stroke Transitional Technology-Enhanced Program (JSTTEP) is an early supported discharge clinic designed to reduce complications and improve outcomes for patients returning home after stroke hospitalization. In this program, patients are seen by a stroke specialist within 1 week of hospital discharge, referred for specialty care as needed in week 2, and participate in targeted stroke education to mitigate individual risk, promote recovery, and enhance self-management. This high-value program brings interprofessional specialty care to the patient with the right resources at the right time after hospitalization. We describe participation in the JSTTEP to promote ongoing management during the dynamic process of post-hospital care to avoid complication and promote high value stroke care.
Results:
Mrs. S was recently hospitalized for stroke due to carotid disease as a manifestation of her multiple medical comorbidities and cancer-specific radiation therapy. During the hospitalization blood pressure was labile and managed with multiple medications to maintain target a blood pressure within a narrow goal to maintain cerebral perfusion and avoid additional stroke. At home, she developed syncope and orthostatic hypotension with fluctuating arm weakness likely secondary to poor nutritional intake. During weekly JSTTEP telemedicine visits medications were titrated and strategies to improve intake were implemented. These ongoing conversations resulted in successful early transition as the patient remained at home, did not have adverse neurologic outcome, and continued cancer treatments without interruption.
Conclusions:
The JSTTEP transitional clinic provides continuity of care and management of dynamic medical issues that are often evolving at the time of hospital discharge. This case demonstrates the success of the program in creating an individualized care plan specific to the stroke and underlying risk factors, ultimately preventing readmission. The readmission quality measure captures this singular outcome, though the process to achieve this outcome is a multifactorial demonstration of high-quality care.
Clinical Implications:
Rates of readmission after stroke are an important summary statistic indicative of high value care. It is important to demonstrate the processes involved in maintaining a high-value transitional stroke clinic on a population level. Describing interval methods to reduce hospital readmission is accomplished through implementing, evaluating, and improving high-value systems to support patient care.