Improving the Con/nuum of Stroke Care A Prac/cal Model for Post- Acute Treatment

Transcription

1 Improving the Con/nuum of Stroke Care A Prac/cal Model for Post- Acute Treatment PRESENTED BY: Pamela W Duncan PhD, FAPTA: Professor of Neurology, Senior Policy Advisor for Transi=ons and Outcomes, Wake Forest Bap=st Health Cheryl Bushnell, MD, MHS: Professor of Neurology, Director, Wake Forest Bap=st Health, Comprehensive Stroke Center

2 Audience Polling Question #1 2

3 Audience Polling Question #2 3

4 Guest Speakers Pamela W Duncan PhD, FAPTA Professor of Neurology, Senior Policy Advisor for Transi=ons and Outcomes Cheryl Bushnell, MD, MHS Professor of Neurology Director, WFB Comprehensive Stroke Center Wake Forest Baptist Health 13

5 Improving the Continuum of Stroke Care A Call for Action

6 What happens to stroke pa=ents ajer discharge now? 6

7 Stroke Care: Many gaps remain Stroke Hyper acute Acute Rehab Community 42% of stroke pa=ents were not referred to any post- acute care (Gage, et al. U.S. DHHS 2009) 65% of pa=ents under age 65 discharged without post- acute services (Be2ger, et al. J Am Heart Assoc 2015) No performance indicators for processes of care ajer discharge 7

8 Patients discharged home 24% readmission rates in 90 days 75% fall in 6 months and if they fall are 4 times as likely to break a hip Less than 30% of stroke survivors have their BP controlled Acute Deficit Free Care is 76% but postacute is only 44% Poor Medication Adherence (75% at 3 months) Wake Forest Baptist Health 17

9 Stroke pa=ent voices 60 year old, white male, living in urban NC, member of the business community A follow-up phone call has got to be the prime piece that has to happen in stroke recovery. After the stroke I had new prescriptions I couldn t dispense my medications into daily doses. This math deficit was not recognized until I got home. I lived alone and I had to take care of myself and I was unable to cope. 9

10 Why Do Pa=ents Have Trouble AJer Discharge? New Disability e.g., 44% cannot walk independently at discharge Falls and fractures Aspira=on pneumonia Deep vein thrombosis Infec=ons Depression Adverse events associated with warfarin therapy Cogni=ve deficits (ojen undetected during acute hospitaliza=on) that interfere with func=on, and risk factor and medica=on management. 10

11 Caregivers Have Trouble ajer Discharge Too Caregivers have Poorer mental health Less social contact and ac=vity Are at increased risk for depression 11

12 What is important to stroke survivors and caregivers? Reassurance that they will get beaer! Preven=ng another stroke Support from peers and health professionals that understand what happens ajer discharge Access to informa=on ajer discharge All providers (stroke experts, primary care, home health, therapists, community services) understand the plan of care 12

13 Key Players in Post- Acute Care Therapists (PT, OT, SLP) Community Resources Pa=ent and Caregiver Stroke Neurology Team Home Health Primary Care 13

14 Transi/ons of care represent great opportuni/es for improved care of stroke pa/ents over the next decade which must start now N W E October 1015 S 23

15 Evidence for interven=ons that improve post- acute care Transi=onal care management (Naylor, et al. Health Affairs 2011;30:45-54) Only covers the first 30 days Early supported discharge (Fearon, et al Cochrane Database Syst Rev 2012) : Hospital- based stroke team provides coordinated care (rehab, preven=on, support) in the home standard of care in U.K. and Canada Never been implemented in the U.S. 15

16 Effects of Post- Acute Care on Pa=ent and Caregiver Evidence from early supported discharge shows that organized post- acute care can: Improve stroke survivor func=onal status with ADLs Reduce the risk of death or ins=tu=onaliza=on Reduce costs Improve pa=ent/caregiver sa=sfac=on No added burden on caregivers 16

17 Evidence for Therapy AJer Stroke Treatment ini=ated within the first 20 days of stroke was associated with a significantly high probability of excellent therapeu=c response. (Paolucci, 2000) Rehabilita=on can improve func=onal outcomes, par=cularly in pa=ents with lesser degrees of impairment. (Duncan 2005) The recovery of treated individuals with communica=on disorders was doubled when treatment began with in 4 months of stroke (Robey, 1994) 17

18 The Challenges Can an interven=on to improve care for stroke pa=ents regardless of the sekngs and providers be adapted to the U.S. health care system? What might be the best sekng for tes=ng a complex interven=on for post- acute care? N Stroke Recovery W Secondary Preven=on S Comprehensive Coordinated Services E 18

19 TRAnsition Coaching for Stroke (TRACS) Neuroscience service line-funded, Neurology department-built Cheryl Bushnell, MD, MHS Professor of Neurology Director, WFB Comprehensive Stroke Center Wake Forest School of Medicine

20 TRACS history FY 2011: investment in personnel to enroll patients and track outcomes using REDcap September 2012: Second stroke NP hired January 2014: RN was added to the team of 2 stroke NPs with task of calling patients 2 days after discharge and allowing for transitional care management billing As of Dec 2015, 675 patients have been enrolled Wake Forest School of Medicine 29

21 TRACS and Stroke Follow-up Clinic NPs assess for risk of readmission > 2 prior admissions in year prior to stroke NIHSS CHF, CAD Stroke complications (UTI, pneumonia, acute renal failure) 1 Socioeconomic or psychosocial issues Discharged on warfarin and/or bridging rx TRACS RN: 2-day phone calls, then standardized and comprehensive stroke NP assessment within 2 weeks. Wake Forest School of Medicine 1. Strowd, et al. Am J Med Quality

22 Factors Associated with 30-day Readmissions Variable NIH Stroke Scale, median (IQR) 30- day readmission (n=46) No 30- day readmission (N=464) P value 3 (1-7) 2 (1-5) Prior hosp. n (%) 16 (34.8) 90 (19.5) Transi/onal Stroke Clinic 28 (60.8) 354 (76.3) visit, n (%) Mul/- risk (DM, CAD, or CHF) None 1 of 3 2 of 3 3 of 3 14(30.4) 22 (47.8) 8 (17.4) 2 (4.4) 244 (52.6) 150 (32.3) 56 (12.1) 14 (3.0) Prior stroke or TIA, n (%) 23 (50.0) 134 (28.9) Follow- up call completed, n (%) 34 (73.9) 364 (78.4) Wake Forest School of Medicine 31

23 Transitional Stroke Clinic Cuts 30-day Readmissions by Half Variable Transi/onal Stroke Clinic visit Mul/ple Comorbidi/es (diabetes, CAD, or CHF) 30- day readmission OR (95% CI) P value (0.272, 0.986) (1.029, 2.076) Prior stroke/tia (1.188, 4.199) Data presented as a plaoorm at the 2016 Interna=onal Stroke Conference by Chris=na Condon, NP- C, manuscript under review by Stroke Wake Forest School of Medicine 32

24 Audience Polling Question #3 24

25 From TRACS to PCORI/COMPASS TRACS model laid the groundwork Wake Forest School of Medicine

26 A Pragma/c Trial for COMprehensive N Post- Acute Stroke Services (COMPASS) Pamela Duncan, W PhD, PT Cheryl Bushnell, MD, MHS Wayne Rosamond, PhD E S 35

27 Acknowledgement Funding This research was supported through a Pa=ent- Centered Outcomes Research Ins=tute (PCORI) Project Program Award (PCS ) Disclaimer All statements in this presenta=on, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Pa=ent- Centered Outcomes Research Ins=tute (PCORI), its Board of Governors or Methodology Commiaee 27 36

28 COMprehensive Post- Acute Stroke Service (COMPASS) Aims Primary aim Determine the compara=ve effec=veness of COMprehensive Post- Acute Stroke Service model vs usual care on stroke survivor func/onal status at 90 days post- stroke Secondary aims Assess caregiver strain at 90 days All- cause readmissions at 30 and 90 days Mortality, health care u=liza=on, use of TCM billing codes using claims data at 1 year 28 37

29 N W E THE CARE MODEL COMprehensive Post- Acute Services (COMPASS) Model S 29 38

30 Finding The Way Forward NUMBERS N NUMBERS Know your numbers: BP; A1C; Cholesterol etc. W WILLINGNESS S SUPPORT E ENGAGE ENGAGE Be ac=ve: Engage your mind, your hands, your arms and your feet SUPPORT Take advantage of Support systems/ resources: Community, Family and caregivers WILLINGNESS Medica=on management: What medica=on are you on? Why are you on them? When do you take them? 30

31 What is COMPASS Transi=onal Care? Includes use of exis=ng and new billing codes through CMS: TCM and CCM Incorpora=on of early supported discharge with stroke- trained APP and RN (post- acute coordinator) 31

32 1. Before Discharge PAC visits the stroke survivor before discharge and provides educa/onal materials about COMPASS and discusses the /mes when the stroke survivor will be contacted by COMPASS staff 32

33 2. Call 2 Days AJer Discharge The PAC calls the stroke survivor and discusses: Concerns with medica=ons New symptoms since discharge Follow- up appointment with PCP The 7-14 day Stroke Clinic visit date, =me and loca=on Signs of stroke and when to come to the ED Services or resources that the survivor may need (home health, falls preven=on, etc.) Photo Credit: 33

34 3. Visit 7-14 Days AJer Discharge During the 7-14 day visit at the Stroke Clinic the survivor will meet with an Advanced Prac/ce Prac//oner and the PAC. The PAC will ask the survivor ques=ons about: Primary care provider Ability perform every day ac=vi=es (bathing, dressing, cooking, making calls, managing medica=ons) Physical mobility and safety Mood and stress level Social support at home Visits to the ED or hospital since the stroke Family caregiver ability to support the stroke survivor The Advanced Prac=ce Prac==oner will: Perform a neurological exam Assess stroke complica=ons Photo Credit: 34

35 APP Evalua=on at Visit Review Hospitaliza=on Post- Stroke Complica=ons & Risk for readmission Expecta=ons for recovery- ongoing therapy needs and referrals Management of blood pressure Physical mobility/ Independence & Safety ecare Plan & Follow up Medica=on Management and barriers Neurological Status or new symptoms 35

36 The Individualized Pa=ent ecare Plan Pamela Duncan, PhD Rica Abboa, MPH

37 Three Medicare Programs Require Comprehensive Assessments 37

38 38

39 Key Goals of the COMPASS ecare Plan Applica=on Goal 1: To know the pa=ent/caregiver: Level of func=on/recovery, risk factors, and preferences Goal 2: To discuss with the pa=ent, family, and health care team the pa=ent s priori=es for care Goal 3: To provide the right care, at the right =me Goal 4: To share the plan across all providers 39

40 ecare Dashboard / Homepage consists of pa=ent demographics, and assessments to be completed. 40

41 A Handoff Report will be created based on pa=ent responses from the Post- Stroke Func=onal Assessment. This report will be viewed by the APP before the Advance Prac=ce Assessment is performed. The purpose of the Handoff Report is to report the domains that are a concern to a pa=ent s health state. Example: Falls 41

42 Informa=on on the Individualized ecare Plan What are my health concerns? Explains issues found through ecare Plan assessments Why is this important to me? Explains how this issue can affect overall health and stroke recovery How do I find my way forward? Provides recommenda=ons and referrals for dealing with the health issue Summa/ve Report A summary report created for pa=ents that are at high risk of readmission Community Resources Page Provides contact informa=on to services that were recommended in the How do I find my way forward column of the ecare Plan 42

43 ecare Plan: Engage 43

44 Accessing Community Resources on ecare Plan Includes basic informa=on about local resources recommended to pa=ents on the How do I find my way forward column of ecare Plan Pa=ents only referred to resources that provide services within their county of residence Providers can customize which resources appear on Community Resources page 44

45 hap:// discover- innova=on/picture- of- health/ 45

46 4. Calls 30 and 60 Days ajer Discharge 30 days and 60 days aher discharge the PAC calls the survivor to: Review the points of the COMPASS (Numbers, Engage, Support, W s) Get a Care Plan Update Provide a reminder of 90- day call from Carolina Survey Research Laboratory and that materials will be mailed 46

47 5. Survey Call 90 Days ajer Discharge A staff member from the Carolina Survey Research Laboratory will call the survivor and caregiver to ask about their recovery 47

48 Quality Improvement and Web-based Feedback Real-Time Feedback based on the processes of the intervention % of patients called within 2 days % of patients seen by NP/PA within 7 days and 14 days % of eligible patients referred to rehabilitation services Wake Forest Baptist Health 57

49 COMPASS Design Cluster- randomized pragma=c trial Hospitals randomized not pa=ents Stra=fica=on by hospital characteris=cs: stroke volume (<100, , and >300) and primary stroke center status (6 strata) Primary outcome: Stroke Impact Scale- 16 at 90 days (pa=ent- reported outcome) Secondary outcomes: Modified Caregiver Strain index at 90 days All- cause readmissions at 30 and 90 days Mortality, health care u=liza=on, use of TCM billing codes using claims data Context: Hospitals Randomized PragmaIc- Health Systems asked to establish infrastructure and processes for TransiIonal Care Management

50 COMPASS: Target Popula=on Inclusion criteria ALL ischemic and hemorrhagic stroke pa=ents who are discharged home from par=cipa=ng hospitals Exclusion criteria Pa=ents discharged to skilled nursing or inpa=ent rehab facility Pa=ents that do not speak English or Spanish Age < 18 years Pragma=c- all pa=ents ( scalability) 50 59

51 Study Design Hospitals Assessed for Eligibility & Interest Randomiza/on COMPASS Interven=on Phase 1 Alloca/on Usual Care 1 Year 1 Year Sustain COMPASS Interven=on Phase 2 Alloca/on COMPASS Interven=on 1 Year 1 Year Sustain COMPASS Interven=on 51 60

52 External Policy and Incen=ves CMS Reimbursement Codes for Transi=onal Care Management CMS Stroke Readmissions Publicly Reported CMS- Expected Bundled Payments for Stroke Home Health Agency 5 Star Quality Repor=ng - Value Based Reimbursement Joint Commission Cer=fied Primary and Comprehensive Stroke Centers 52

53 Audience Polling Question #4 53

54 Questions and Answers

55 On-Demand Webinars 1. Telestroke Bedside Best Prac2ces: Op2mizing Collabora2on between ED Staff and Remote Neurologists 2. Using Telemedicine to Triage Pa2ents for Intraarterial Treatment of AIS 3. Building and Sustaining a Telestroke Network It's More than Technology 4. Telestroke Program Evolu2on: Best Prac2ces from Georgia Regents Medical Center 5. Building a Successful Telestroke Program: Lessons Learned at Penn State Hershey 6. Telemedicine Success How to Effec2vely Promote Your Program reachhealth.com/telemedicine- webinars 55

56 Educational Whitepapers 1. Top Telestroke Myths An Insider Perspec2ve on Addressing and Naviga2ng Challenges 2. Best Prac2ces for Establishing a Telemedicine Network 3. Execu2ve Guide to Selec2ng a Telemedicine PlaWorm How to Choose Pragma2cally for Today and Prepare Strategically for Tomorrow 4. Telestroke Best Prac2ces: Reducing Time to Treatment Prac2cal Advice for Minimizing Door- to- Needle and Door- to- Puncture Times reachhealth.com/telemedicine- whitepapers 56

57 Thank you for your par2cipa2on Please be sure to provide your feedback in the exit survey