Creating Stroke Systems of Care Elyas Bakhtiari, for HealthLeaders Magazine, June 9, 2010

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1 Creating Stroke Systems of Care Elyas Bakhtiari, for HealthLeaders Magazine, June 9, 2010 If U.S. healthcare is headed toward a model that eliminates fragmentation and emphasizes continuity and cooperation, stroke care may be leading the way and making a difference in patients' lives. A few years ago an American Stroke Association task force set a new bar for stroke care delivery: Successful treatment of stroke can't be thought of as a single inpatient procedure. Instead, stroke care should be provided in a system that involves coordination along the entire care continuum, from primary prevention through rehabilitation. Stroke is a complex and time-sensitive disease that requires equally complex approaches to treatment. Although there have been major advances in clinical treatments in recent years, the best medicine matters little if the patient doesn't get treatment fast enough to prevent death or disability. And although many hospitals have improved the speed and coordination of their own care teams, many patients live too far away to reach the best stroke centers in time. Individually, advances in treatment and in care delivery will do little to stem the tide of stroke mortalities unless hospitals and physicians can put all the pieces of the puzzle together. "For us to be successful at really achieving the goals of reducing death and disability from stroke, we have to look across the whole system," says Ralph Sacco, MD, president-elect of the American Heart Association and chair of neurology at the University of Miami Miller School of Medicine. The ASA estimates that if every state had stroke systems of care in place, the country could make significant progress toward the organization's 2010 impact goal to achieve a 25% reduction in coronary heart disease, stroke, and risk. One of the most challenging steps in building that type of system can be creating a network for acute and sub-acute care. It's not efficient to have all the capabilities of a comprehensive stroke center (which provides interventional and high-tech stroke treatments) at every hospital, says Sacco. Instead, stroke centers are developing into hub and spoke networks that help extend advanced stroke care to regions that otherwise wouldn't have the resources. For instance, in a properly designed system, a patient in a rural area without a comprehensive stroke center would only have to worry about getting to the nearest hospital once symptoms start. That spoke hospital would have access to on-call neurologists at a hub, via telemedicine, and could then stabilize the patient. If the stroke required more complicated intervention, the patient would then be transferred to the comprehensive center.

2 Building these networks requires more than technology, however. Numerous leadership challenges accompany coordination between several (sometimes competing) hospitals. But hospitals large and small, as well as patients and providers, will ultimately benefit if they can achieve the teamwork needed to create a true system. Success Key No. 1: Build beneficial partnerships St. Luke's Episcopal Health System, a four-hospital system based out of Houston, was an early adopter of the stroke center model, receiving its first Joint Commission certification in 2004 and upgrading to a comprehensive center in subsequent years. To expand the program, leaders recently signed agreements with five hospitals outside of the system that will serve as spokes in St. Luke's stroke care network. St. Luke's was motivated to build the network by two characteristics of the local market that mirror nationwide trends in stroke care. The first was simply struggles in rural physician recruitment. "We were approached by several hospitals in rural areas interested in taking care of stroke patients but struggling with the acute management of those patients in emergency room... They didn't have the neurological and the neurosurgical support to care for the more acute patients," says Sarah Livesay, manager of neuroscience clinical programs at St. Luke's. The second factor was related to legislation that the state of Texas was considering that would encourage patients to receive care at certified stroke centers. Several states and cities across the country have passed or are considering similar laws, which generally allow emergency medical services to take patients to the nearest certified hospital, bypassing a closer hospital that doesn't have the qualifications (if they have time). Because of the legislative pressure, rural hospitals lacking the physician support for 24/7 stroke coverage were faced with the prospect of losing stroke patients if they didn't improve their programs. Becoming a spoke in St. Luke's network helped solve this problem. Thanks to telemedicine, St. Luke's physicians can provide around-the-clock consultative call coverage to partner hospitals. Livesay says this mutually beneficial relationship is essential to building a successful system. "We make it clear from the get-go that we're not taking all their stroke patients or keeping them from growing. By partnering in this relationship it will help them grow their service line." Because private practice neurologists in smaller communities are increasingly reluctant to take call, the telestroke coverage from a hub allows smaller hospitals to maintain good physician relations while still keeping up stroke volume. St. Luke's has three neurocritcal care intensivists to provide that coverage at Baylor College of Medicine in Houston. If the spoke hospital is able to successfully treat the patient using only the telestroke assistance, then the patient stays put. But the moment that the severity of the stroke patient exceeds the spoke hospital's capabilities if the patient requires neurosurgical intervention or post-tpa management, for example he or she can be transferred to St. Luke's for more comprehensive treatment.

3 Ideally, the increase in basic stroke patients at the spoke hospital and complex ones at the hub help both service lines grow. Success Key No. 2: Figure out reimbursement Physician buy-in is absolutely essential to pulling off a telestroke network, Livesay says. While early communication and other physician relations strategies are important to getting doctors onboard, reimbursement is a major concern that can't be overlooked. However, the guidelines for telestroke reimbursement are still inchoate and tough to interpret. St. Luke's researched several different models when setting up its network. One option is a sort of fee-for-service model between the spoke hospital and the on-call physicians where the doctor receives a predetermined payment for every connection he or she makes with the spoke hospital. Some spoke hospitals instead prefer to pay the physicians a flat monthly or yearly fee for their telestroke services. In other cases, the spoke hospitals don't bill at all and let physicians handle their own reimbursement for the services. There are benefits and drawbacks to each approach, and the best fit depends in part on individual preferences and whether the physicians are employed or in private practice. Most doctors, for example, don't like to bill for their own telestroke services because there can be so much variation among payers. Baylor College of Medicine physicians contract with spoke hospitals for a yearly fee that covers telestroke consultations. This is all set up directly between the physicians and the spoke hospital, says Livesay. St. Luke's has a transfer agreement with the spoke hospitals, but aside from research into various models and overall support, doesn't get directly involved in reimbursement negotiations. "We spent a lot of time trying to work through the details of billing and compliance issues," says Boyd. "That's a market that's changing regularly." Success Key No. 3: Don't overinvest in technology A few decades ago, building these regional systems of care wouldn't have been as easy. Technology, and telestroke in particular, has enabled the entire movement toward systems-based care to take place. But hospitals should avoid placing too much emphasis on the technology elements of the program, says Connie L. Boyd, service line director for neurosciences and oncology at St. Luke's. A secure laptop and webcam setup is all that St. Luke's needs to coordinate with spoke hospitals, she says. Some software and hardware packages require large investments, which a lot of smaller hospitals may not be able to make. That's why St. Luke's purposefully decided that technology would not be the primary focus when it began exploring telemedicine.

4 "Don't jump too quickly," Livesay cautions. "The market is changing rapidly. The technology and software packages are going to look different in several years." Instead, focus on a few basic questions: Is it secure? Is the connection reliable? Can providers share necessary information? More advanced telestroke systems that incorporate robots and other high-end technology are certainly an option for the systems that can afford them. But it's important to remember that even the best technology will fall short if leadership doesn't build the infrastructure and relationships to make the network work, says Livesay. Success Key No. 4: Seek certification As more regional networks begin to spread, each facility has to determine its desired role as a stroke care provider within a larger system. Being a hub hospital sounds like a nice volume driver, but becoming a comprehensive center takes a lot of investment in technology and specialists. Even primary center certification can be a tall order for hospitals without existing stroke programs. "As a hospital CEO, you have to decide for your own community what the market looks like, identify the other stroke centers, and recognize that it is an investment to become a primary stroke center," says Sacco. But as more states add certification requirements that allow EMS diversion, getting certified as a primary stroke center either by The Joint Commission, a state agency, or an organization like DNV Healthcare may become a necessity. Certification isn't just another hoop to jump through, however. Programs that meet the various requirements for primary stroke center certification tend to have better-quality results and higherperforming teams. Sharp HealthCare has used the American Heart Association's Get with the Guidelines certification assistance program for several hospitals in its system, all of which provide different levels of stroke care, says Mary Elington, director of orthopedic and neurological services at Sharp Healthcare. For instance, although it has been using the Get with the Guidelines program for nearly five years, Sharp Memorial Hospital was only certified as a primary stroke center in Implementing the guidelines early helped improve the overall quality of the program, Elington says. "We use that as our vehicle for quality improvement and performance improvement. We track all Joint Commission measures and quality care process measures," she says. "We use that for our process improvement and to track how well we're doing." One of the biggest challenges has been ongoing staff education requirements. The certification guidelines push hospitals to develop dedicated stroke care teams that have unique training.

5 If you don't have that kind of a unit where the care is concentrated to those patient populations, and they're mixed into the general med-surg population, she says, you have challenges making sure all nursing personnel are up to speed to get measures done and meet patient needs. As more hospitals successfully receive primary stroke center certification, the next logical step looks to be certification for comprehensive stroke centers. Most certifying bodies don't distinguish between the two, but in order to expand the systems of care model in the future, comprehensive stroke centers may have to meet additional guidelines to demonstrate their ability to accept transfer patients and perform interventions on severe cases. Success Key No. 5: Track and share outcomes One of the key components of a stroke system of care identified by the American Stroke Association was continuous quality improvement initiatives. This is important not only within an individual stroke center, but between spokes and hubs within a network. St. Luke's quality improvement efforts center on tracking and sharing outcomes. The governance committee meets quarterly with spoke hospitals to share outcomes data. Together, they look for variances in the data and try to collaboratively improve patient transfers and clinical processes. But the real challenge for stroke care is moving from quality performance measures to true outcome measures. "We can always track outcome measures during hospitalization. What we're really looking for is outcomes at 30 or 90 days post stroke. That's a little trickier to track," says Sacco. St. Luke's engages physicians at rehab facilities as well to ensure coordination of care extends beyond the acute care phase. Some spoke hospitals have their own in-house rehab services, and coordinating between the various settings makes tracking outcomes longitudinally a little easier. The National Institutes of Health stroke scale and Rankin scale are two options that more stroke centers are using to get a sense of health outcomes. Both track motor skills, speech recognition, and other stroke recovery indicators and can be used over time to quantify not just if a patient lived or died after a stroke, but how well he or she is returning to normal. More detailed outcome measures not only help with readmissions, but they can also help sell the value of all these stroke systems of care to other disciplines. Setting up a system requires significant investments of time and resources from multiple departments. If a hospital can show that 70% of people with a 0 Rankin score before intervention have returned to normal, it may be easier to get buy-in from ED physicians and other providers. Elyas Bakhtiari is a freelance editor for HealthLeaders Media.

6 Components of Care The American Stroke Association recommends that stroke systems of care include six components: Primordial and primary prevention Notification and response of emergency medical services for stroke Acute treatment for stroke Subacute stroke care and secondary prevention for stroke Rehabilitation of stroke patients Continuous quality improvement initiatives SOURCE: American Stroke Association; Back