Truly comprehensive stroke care: A High value, post-discharge system for improved patient success

From the 2023 HVPA National Conference

Mona Bahouth MD, PhD (Johns Hopkins School of Medicine),  Amelia Tenberg MSN, Elizabeth Zink 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. Optimal post-stroke recovery can be derailed by destabilized comorbid conditions, hospital readmission, delays in initiating rehabilitation, and inadequate education on self-management of vascular risk factors. This period is also the critical window for brain repair and therefore treatments and complications in this period have lasting positive or negative effects. To date, there is little support in the immediate post-hospital discharge period. Therefore, we developed the Joint Stroke Transitional Technology-Enhanced Program (JSTTEP) to support patients, assure continuity of care, reduce complications, and improve patient outcomes.

Objective:
To describe the impact of the JSTTEP related to access to specialty care and reduction of low value resource utilization after hospitalization for stroke.

Methods:
The JSTTEP is an interprofessional program comprised of a series of joint telemedicine visits completed within one month of hospitalization. The patient is seen prior to hospital discharge by the stroke nurse practitioner during which time the patient is introduced to the JSTTEP process and handoff from the hospital nurse is received. The overall goal of the 3-part JSTTEP is to assure continuity of care, avoid post-stroke complications, solidify education, and improve patient outcomes. This program also improves continuity with communication to the primary provider and has the potential to reduce healthcare costs by reducing redundancy of testing.

Results:
The JSTTEP has been operational since March 2020 and performed over 700 visits to date. Average time to first visit is 9 days from hospital discharge (previously 2-3 month delay). The average age of the cohort is 62 years; 48% are male, 48% are African American. No patients are turned away based on insurance status. Currently, 84% of scheduled JSTTEP visits with the neurology provider are completed, which is significantly higher than the average visit completion visit rate for stroke neurology follow-up prior to the intervention. With the implementation of JSTTEP, we increased the percent of hospitalized stroke patients who were seen within 30 days of hospitalization from 12% (pre-JSTTEP) to 40% (post-JSTTEP). Hospital 30-day readmission rates were lower for JSTTEP participants compared to national reports; 8% versus 12%, respectively. Through JSTTEP, we have identified numerous safety and functional issues that were resolved expeditiously by the multidisciplinary team including home environment assessment, blood pressure management, resolution of medication issues, support with use of prescribed technologies, and interventions to facilitate earlier access to rehabilitation services and promote recovery.

Conclusions:
Early supported discharge with the JSTTEP model is of high value to the stroke patient. Access to specialists immediately after hospital discharge is the key to promoting improved safety during a highly vulnerable time period. Together we are empowering the patient, reducing patient burden, and avoiding unnecessary readmissions to the hospital.

Clinical Implications:
The JSTTEP is an innovative program that delivers interprofessional specialty care to the patient with the right resources and at the right time after hospitalization. JSTTEP extends stroke team expertise from the hospital into the outpatient setting. This model is scalable and has been replicated in other disease models. Our team is in process of measuring long term effect and disseminating similar programs nationally.

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