Abstract TMP77: Development of a Collaborative Transition Coaching Program for Reduction of Post-stroke Hospitalizations

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Ann M Leonhardt ◽  
Denise M Burgen ◽  
Jennifer Wolfe ◽  
Kelly Luther
Keyword(s):  
Ischemic Stroke ◽  
Home Care ◽  
Hospital Readmission ◽  
Fiscal Year ◽  
Pilot Program ◽  
Stroke Patients ◽  
Stroke Population ◽  
Essential Components ◽  
Care Agency ◽  
Home Care Agency

Issue: All-cause 30 day hospital readmission rate following discharge for ischemic stroke has been instituted by CMS as a quality measure. Successful readmission reduction planning is a hospital imperative. Purpose: We set out to establish a stroke-specific transitions coaching program with the intention of decreasing readmissions in our ischemic stroke population. Methods: Fiscal year 2013 stroke readmissions to our hospital were individually reviewed for factors leading to readmission. After determining 62.5% of avoidable readmissions were attributed to outpatient factors, a regional home care agency was contacted for collaboration. The agency has proven readmission reductions utilizing the Coleman Care Transitions Model. This model incorporates visits prior to discharge, by telephone, and at home by a trained transitions coach to ensure understanding of medications, follow up visits, and recognition of concerning symptoms. Cost estimates for expanding the program to stroke patients were made using the prior year’s volume based on primary payer, county, and discharge destination. A business plan was established and training and informational sessions planned. Results: Of the outpatient factors contributing to readmission the most common were medication issues, seeking emergency care prematurely, and need for education or support. Based on the data and prior successes of the home care agency a pilot program was developed. The estimated cost for patients not covered by their primary insurance is $52,000 annually. The estimated cost for one hospital readmission is $11,200. Preventing 5 readmissions per year would save $56,000. A successful collaborative was formed resulting in the ability to enroll a larger number of ischemic stroke patients in the transitions coaching program. Conclusions: Solving the problem of readmissions after ischemic stroke is complex and requires extensive planning and collaboration. Identifying our issues and establishing a pilot program took nearly a year. Key stakeholders and a committed team are essential components of establishing a collaborative process of this magnitude. The pilot program will be evaluated by comparting readmission rates in the ischemic stroke population pre and post initiation.

Abstract 23: Reducing Stroke Readmissions Utilizing a Home Care Based Transitions Coaching Program

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ann M Leonhardt Caprio ◽  
Denise M Burgen ◽  
Curtis G Benesch
Keyword(s):  
Ischemic Stroke ◽  
Home Care ◽  
Hospital Readmissions ◽  
Care Transitions ◽  
Hospital Inpatient ◽  
Pilot Program ◽  
Readmission Rates ◽  
Specific Patient ◽  
Care Agency ◽  
Home Care Agency

Background: The Center for Medicare and Medicaid Services (CMS) has instituted utilization of all-cause, unplanned 30 day hospital readmissions following discharge for ischemic stroke as part of the Hospital Inpatient Quality Reporting Program. While readmission reduction following stroke is a hospital imperative, there is minimal evidence on stroke-specific readmission reduction programs. Purpose: We sought to reduce 30 day readmissions following ischemic stroke through utilization of an established care transitions program in collaboration with our institution’s affiliated home care agency. Methods: Our institution’s home care agency has reduced readmission rates in the general medical population utilizing the Coleman Care Transitions Model © . This model incorporates motivational interviewing in visits prior to hospital discharge, with a home visit 24 to 48 hours after discharge, and by telephone at least weekly by a trained transitions coach. The coach ensures understanding of medications, follow up visits, and recognition of red flag symptoms. A one year pilot program for stroke patients utilizing this established program was initiated in October 2015. Basic stroke training was provided for all coaching staff. Quarterly readmission rates for 1 year prior to the intervention and 6 months following were analyzed. Results: During the first 6 months of the pilot program 18.2% of patients discharged with a diagnosis of ischemic stroke qualified for and completed the coaching program. Of those in the program 3.3% were readmitted. Overall, there were 15 readmissions in 13 patients, 85% of whom did not receive transitions coaching services. The readmission rate in the year prior to intervention was 7.8%, in the 6 months following 4.5%. These findings represent a 42.7% overall reduction in readmissions (p = 0.06) and a treatment effect of 1.7. Conclusions: Utilizing the Coleman Care Transitions Model © led to a meaningful reduction of hospital readmissions for patients with ischemic stroke in this pilot program. In an area in which readmission reduction has proven challenging, expanding the availability of a home care based program for specific patient populations may be an effective strategy.

scholarly journals Facilitating co-production in public services: Empirical evidence from a co-design experience with family caregivers living in a remote and rural area

2020 ◽  
pp. 095148482097145
Author(s):  
Eleonora Gheduzzi ◽  
Niccolò Morelli ◽  
Guendalina Graffigna ◽  
Cristina Masella
Keyword(s):  
Home Care ◽  
Family Caregivers ◽  
Empirical Evidence ◽  
Rural Area ◽  
Public Service ◽  
Rural Areas ◽  
Crucial Role ◽  
Care Agency ◽  
Home Care Agency ◽  
Design Experience

The involvement of vulnerable actors in co-production activities is a debated topic in the current public service literature. While vulnerable actors should have the same opportunities to be involved as other actors, they may not have the needed competences, skills and attitudes to contribute to this process. This paper is part of a broader project on family caregivers’ engagement in remote and rural areas. In particular, it investigates how to facilitate co-production by looking at four co-design workshops with family caregivers, representatives of a local home care agency and researchers. The transcripts of the workshops were coded using NVivo, and the data were analysed based on the existing theory about co-production. Two main findings were identified from the analysis. First, the adoption of co-production by vulnerable actors may occur in conjunction with other forms of engagement. Second, the interactions among facilitators and providers play a crucial role in encouraging the adoption of co-production. We identified at least two strategies that may help facilitators and providers achieve that goal. However, there is a need for an in-depth understanding of how facilitators and providers should interact to enhance implementation of co-production.

scholarly journals Ischemic stroke with a preceding Trans ischemic attack(TIA) less than 24 hours: Predicting clinical risk factors for thrombolytic therapy

2019 ◽  
Author(s):  
Nicolas Poupore ◽  
Dan Strat ◽  
Tristan Mackey ◽  
Ashley Snell ◽  
Thomas Nathaniel
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Thrombolytic Therapy ◽  
Older Patients ◽  
Clinical Risk Factors ◽  
Receiver Operating Curve ◽  
Stroke Patients ◽  
Clinical Risk ◽  
Stroke Population ◽  
Clinical Risks

Abstract Background Acute ischemic stroke attack with and without a recent TIA within or less than 24 hours may differ in clinical risk factors, and this may affect treatment outcomes following thrombolytic therapy. We examined whether the odds of exclusion or inclusion for thrombolytic therapy are greater in ischemic stroke with TIA less than 24 hours preceding ischemic stroke(TIA-24hr-ischemic stroke patients) as compared to those without recent TIA or non-TIA <24 hours.Methods A retrospective hospital-based analysis was conducted on 6,315 ischemic stroke patients, of whom 846 had proven brain diffusion-weighted magnetic resonance imaging (DW-MRI) of an antecedent TIA within 24 hours prior to ischemic stroke. The logistic regression model was developed to generate odds ratios (OR) to determine clinical factors that may increase the likelihood of exclusion or inclusion for thrombolytic therapy. The validity of the model was tested using a Hosmer-Lemeshow test, while the Receiver Operating Curve (ROC) was used to test the sensitivity of our model.Results In TIA-24hr-ischemic stroke population, patients with a history of alcohol abuse (OR = 5.525, 95% CI, 1.003-30.434, p = 0.05), migraine (OR=4.277, 95% CI, 1.095-16.703, p=0.037), and increasing NIHSS score (OR=1.156, 95% CI, 1.058-1.263, p = 0.001) were associated with the increasing odds of receiving rtPA, while older patients (OR = 0.965, 95% CI, 0.934‐0.997, P = 0.033) were associated with the increasing odds of not receiving rtPA.Conclusion In TIA-24hr-ischemic stroke patients, older patients with higher INR values are associated with increasing odds of exclusion from thrombolytic therapy. Our findings demonstrate clinical risks factors that can be targeted to improve the use and eligibility for rtPA in in TIA-24hr-ischemic stroke patients.

scholarly journals Can clinical risk factors predict functional recovery in ischemic stroke patients with pre-stroke depression?

2019 ◽  
Author(s):  
Leah Wormack ◽  
Brice Blum ◽  
Benjamin Bailes ◽  
Thomas Nathaniel
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Functional Outcome ◽  
Clinical Risk Factors ◽  
Stroke Patients ◽  
Antihypertensive Medications ◽  
Clinical Risk ◽  
Predictive Variables ◽  
Stroke Population ◽  
Thrombolysis Therapy

Abstract Background. Specific clinical risk factors that may be associated with ambulatory outcome following thrombolysis therapy in ischemic stroke patients with pre-stroke depression is not fully understood. This was investigated. Methods. Multivariate analyses were performed to identify predictors of functional ambulatory outcomes. Patient demographics and clinical risk factors served as predictive variables, while improvement or no improvement in ambulatory outcome was considered as the primary outcome. Results. A total of 595 of these patients received rtPA of which 310 patients presented with pre-stroke depression, 217 had no improvement in functional outcome, while 93 patients presented with an improvement in functional outcome. Carotid artery stenosis (OR= 11.577, 95% CI, 1.281 – 104.636, P=0.029) and peripheral vascular disease (OR= 18.040, 95% CI, 2.956-110.086, P=0.002) were more likely to be associated with an improvement in ambulation. Antihypertensive medications (OR= 7.810, 95% CI, 1.401 –43.529, P=0.019),previous TIA (OR= 0.444, 95% CI, 0.517 –0.971, P=0.012), and congestive heart failure (OR= 0.217, 95% CI, 0.318 –0.402, P=0.030) were associated with a no improvement in ambulation. Conclusion. After adjustment for covariates, more clinical risk factors were associated with no improvement when compared with improvement in functional outcome following thrombolysis therapy in an acute ischemic stroke population with pre-stroke depression.

410 Sleep and Stroke: Improved OSA Time to Diagnosis for Stroke Patients Using an Inpatient Diagnostic and Treatment Strategy

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A163-A163
Author(s):  
Sree Naik ◽  
Ramin Zand ◽  
Nada El Andary ◽  
Anne Marie Morse
Keyword(s):  
Ischemic Stroke ◽  
Sleep Apnea ◽  
Recurrent Stroke ◽  
Statistical Significance ◽  
Screening Method ◽  
Stroke Patients ◽  
Stroke Population ◽  
Obstructive Sleep ◽  
Time To Diagnosis ◽  
Home Sleep Apnea Testing

Abstract Introduction Obstructive sleep apnea (OSA) is an independent risk for development of stroke. Despite this known relationship there is insufficient screening of sleep apnea in many recognized stroke centers, including Geisinger. In 2016, 68 patients were admitted to Geisinger Wyoming Valley (GWV) with ischemic stroke. Less than 10% had a Sleep Medicine Referral. When referred, average time to CPAP initiation was 9–12 months. An ongoing quality improvement (QI) study implemented inpatient home sleep apnea testing (HSAT) for stroke patients and subsequent autoPAP, if positive. Interim analysis demonstrates high rates of OSA using this screening method, suggesting a viable mechanism for improved time to OSA diagnosis. Methods All patients at GWV evaluated by neurology due to acute neurologic change were considered for enrollment (9/1/2019-10/10/2020). Only patients 18 years and older hospitalized with diagnosis of ischemic stroke were included. Patients were consented for participation. The evening of enrollment an Alice NightOne HSAT device was applied by a respiratory technician. If OSA was identified, the patient was placed on APAP the following evening. Results A total of 302 patients were screened with 82 patients meeting criteria for enrollment (27%) and 64 consenting for participation and attempting HSAT (21%). 18 of the 82 (22%) eligible patients refused participation. 12 patients (19%) had insufficient HSAT studies to determine OSA diagnosis. Of the patients who successfully completed an adequate HSAT study 85% (44/52) had OSA identified. Conclusion OSA is highly prevalent in patients with ischemic stroke and represents a modifiable risk factor for recurrent stroke. At baseline, rate of and time to diagnosis of OSA was poor with less than 10% of stroke patients receiving a sleep referral and time to initiation of CPAP was approximately 1 year. Standard universal in hospital surveillance for OSA using an HSAT in admitted stroke patients appears to allow for an increased rate of capture, but perhaps also a shorter time to diagnosis. This data may also suggest that prevalence of OSA in this stroke population is similar to slightly higher than previously reported. Further analysis of this program is required to evaluate for statistical significance and impact of APAP use. Support (if any) Geisinger Health Plan

Abstract WP359: Microembolic Signals Are Associated With Stroke Readmission in Patients With Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Nasir Fakhri ◽  
Simin Mahinrad ◽  
Arth Srivastava ◽  
Eric Liotta ◽  
Richard Bernstein ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Recurrent Stroke ◽  
Incidence Rates ◽  
High Risk Population ◽  
Stroke Patients ◽  
Entire Cohort ◽  
Cox Proportional Hazard ◽  
Stroke Population ◽  
Cox Proportional Hazard Models ◽  
Ischemic Attack

Background: Microembolic signals (MES) identified by transcranial Doppler (TCD) are strong predictors of recurrent stroke in patients with carotid disease. In this study, we investigated the association of MES with transient ischemic attack (TIA) or stroke readmission among ischemic stroke patients. Methods: We included a total of 789 patients (mean age 62±17 years, 55% male) who were consecutively admitted to Northwestern Memorial hospital with a diagnosis of stroke. All patients who underwent TCD studies within the first 48 hours of admission were included. Using an electronic database warehouse, patients were followed during 12 months for any hospital readmission due to ischemic stroke or TIA. Risk of stroke readmission was estimated using multivariate Cox proportional hazard models. Results: MES were detected in 95 patients on admission. During 12 months of follow-up, incidence rates for stroke and TIA readmission, and stroke readmission alone were 23.0 and 7.0 per 100 person-years across the entire cohort, respectively. In multivariate adjusted models, patients with MES, as compared to patients without MES, had 1.80-fold (95% CI=1.07, 2.53; p =0.008) higher risk of stroke and TIA readmission, and 2.30-fold (95% CI=1.13, 4.67, p =0.021) higher risk of readmission due to stroke alone. Conclusion: We showed that the presence of MES early after stroke admission is associated with higher risk of stroke and TIA readmission in stroke patients. This not only highlights the importance of identifying MES in the stroke population upon first admission, but also the need to further identify and implement therapeutic strategies to reduce stroke burden and prevent readmission in this high-risk population.

scholarly journals The Frequency of Phospholipid Antibodies in an Unselected Stroke Population

1998 ◽  
Vol 25 (1) ◽  
pp. 64-69 ◽  
Author(s):  
L.M. Metz ◽  
S. Edworthy ◽  
R. Mydlarski ◽  
M.J. Fritzler
Keyword(s):  
Ischemic Stroke ◽  
Systemic Sclerosis ◽  
Antiphospholipid Antibodies ◽  
Anticardiolipin Antibodies ◽  
Activated Partial Thromboplastin Time ◽  
Systemic Lupus Erythematosis ◽  
Stroke Patients ◽  
Systemic Lupus ◽  
Stroke Population

ABSTRACT:Background:Antibodies to cardiolipin and other phospholipids have been associated with recurrent thrombotic events, including stroke.Methods:Over a 16 month period we assessed an unselected cohort of 151 ischemic stroke patients for the presence of antiphospholipid antibodies. Patients with known systemic lupus erythematosis, systemic sclerosis, or Sjogrens Syndrome were excluded. Sera from patients admitted to hospital with a diagnosis of ischemic stroke (n = 151) and from controls (n = 111) assessed during the same period were tested for antiphospholipid antibodies (APLA) using 3 assays; anticardiolipin antibodies (ACA) by ELISA, prolonged activated partial thromboplastin time (APTT), and VDRL.Results:The average age of ischemic stroke cases was 68 years (range 29 to 91) and of controls 63 years (range 29 to 86). The prevalence of APLA detected by at least one of the three methods was 12% for IS cases and 10% for controls. After correcting for known risk factors such as age, gender, diabetes mellitus, heart disease, hypertension, and smoking, the odds ratio for risk of stroke fell to 0.8 (C.I. 0.4 to 1.2).Conclusions:Our findings suggest that APLA may not be an independent risk factor for ischemic stroke in unselected persons who do not have known systemic lupus erythematosis or systemic sclerosis but further evaluation of the role of lupus anticoagulant is indicated.

Hospice in an existing home care agency

1982 ◽  
Vol 5 (3) ◽  
pp. 11-20 ◽  
Author(s):  
Claire Tehan
Keyword(s):  
Home Care ◽  
Care Agency ◽  
Home Care Agency
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