here - Health Services and Systems Research

Mind the Gap: Supporting

Successful Care Transitions and

Recovery after a Stroke

Janet Prvu Bettger, ScD, FAHA – janet.bettger@duke.edu

Associate Professor of Nursing and Senior Fellow in Aging

Faculty Affiliate, Duke Global Health and Clinical Research Institutes

June 24, 2014

Presentation Outline

• Burden of stroke

• Systems perspective of stroke care

• Evidence gaps

• Care models for improved recovery from stroke

All Rights Reserved, Duke Medicine 2007

Projected Deaths by Cause for

High-, Middle- and Low-Income Countries

Other NCDs

Cancers

CVD


Burden of Stroke: DALY


Leading cause of serious, longterm disability in the US

Johnston et al. Lancet Neurol 2009;8:345-54

Burden of Stroke in the United States (US)

• Incidence: 795,000 new or recurrent stroke each year

• Every 40 seconds someone in the US has a stroke

• Every 4 minutes, someone dies of a stroke

• 3 of 4 stroke survivors are dependent at some level for selfcare

• Over 60% of stroke patients have cognitive impairment

• About 15%-30% are permanently disabled

• Stroke survivors requiring constant care 3 months following their stroke have a 7-fold increased 1-year mortality risk

AHA Heart Disease and Stroke Statistics 2014 Update/ CDC National Vital Statistics Reports 2010


Challenges Specific to Stroke Care

• Average length of acute hospital stay = 4 days

• Episode of care for stroke = 82-109 days

• Almost 80% of stroke patients experience more than two transitions of care after hospital discharge

• 1 in 3 are rehospitalized within 3 months

• 1 in 3 are institutionalized in a nursing home within 6 months


Once someone has a stroke…

WHERE ARE OUR

INTERVENTION POINTS?


Stroke System of Care and Transitions in Care

Community

Response

EMS Acute Care

Rehab &

Recovery


A Critical Intervention Point

General Population

Population

At-Risk

The Transition to

Post-Acute Care

Acute

Care

Living in Community

Post-Acute

Care &

Rehab

Living in LTC

Olson DM, Prvu Bettger J, Alexander KP, et al. AHRQ 2011


Medicare Beneficiaries: Comparing patients’ 1 st post-acute setting for all dx to stroke

70

60

50

40

%

30

20

10

0

D/C to PAC

All Medicare

Stroke

IRF SNF LTAC HH Outpatient

Inpatient Community


Evidence-based Information is Lacking to Guide

Delivery of Stroke Care After Hospital Discharge

• What services should a stroke patient receive after being hospitalized for an acute stroke?

– Compare post-acute and transitional care treatment options that matter to patients and their caregivers

– Focus on outcomes of interest to patients and their caregivers

• What strategies should be in place to improve the transition from inpatient care and improve longerterm outcomes?




Services After Acute Care

Care Following the Acute Hospitalization

153,775 Acute Ischemic Stroke Patients in GWTG w/ Medicare FFS Parts A+B Alive at Hospital

Discharge (2006-2008)

51.1% Discharged to Short-term

Inpatient Postacute Care

24.1% Inpatient

Rehabilitation

Facility or Unit

(N=37,064)

27.0% Skilled

Nursing Facility

(N=41,457)

14.9% Home

Health

(N=22,875)

48.9% Discharged from the Hospital to the Community

7.1% Outpatient

Rehabilitation

(N=10,982)

26.9% No

Post-acute Care

(N=41,397)


…to generate key evidence that can be used to guide a critical decision faced by stroke survivors, their caregivers and health care providers every day, almost 1 million times a year… what services to choose following an acute stroke hospitalization

?

A TREMENDOUS OPPORTUNITY


Specific Aims

(what we promised we would do … at a high level)

1. Identify the factors associated with stroke survivors’ use of rehabilitation and health care services following hospital discharge (who gets what services and why based on our data)

2. Compare high intensity rehabilitation (provided in inpatient rehabilitation facilities; IRF) and low intensity rehabilitation (provided in skilled nursing facilities; SNF) on several outcomes

3. Compare outpatient (OP) rehabilitation and home health (HH), and how either are better than no rehabilitation.

4. Compare PCP and neurologist follow-up on outcomes


Who are we studying and how?

This is a study using existing data of adults who had a stroke in

2006-2008.

The person had to have been treated in a hospital participating in the Get With The

Guidelines-Stroke program.

Medicare

FFS

AVAIL

Cohort

GWTG-

Stroke

The person had to be a

Medicare fee-for-service beneficiary for health care.

Some were in a prospective cohort study, AVAIL.


PCORI Population

Outcomes from Claims Data

Outcomes Definition Timing

Hospital readmission All-cause readmission 30 and 90 days

Time to hospital readmission Time in days from index hospitalization to readmission

Long-term care placement Nursing home = residence (nursing facility assessment CPT code AND place of service code with no associated SNF claim)

Up to 12 months

12 months

Survival (analyzed as death) Mortality (alive/not; will use for death & disability) 12 months

Survival Time in days from index hospitalization to date of death

Up to 12 months

Home-time Up to 12 months

Health care utilization

(proxy for cost)

Number of days from hospital discharge to 12 months without inpatient services, a rehospitalization or LTC admit

All billable services

(inpatient days, ED visits, observation stays & provider visits)

30 and 90 days


Patient Reported Outcomes

Outcomes Definition Timing

Primary: living independently Alive, community-dwelling, modified Rankin (mRS) 0-2 3 &12 mo.

Functionally independent

Change in function

Depression

Persistent depression

Return to work

Medication adherence

Smoking cessation

Quality of life

Change in quality of life mRS 0-1

+/- 1 or > change in mRS from 3 to 12 months

PHQ-8 >10

PHQ-8 >10 at 3 and 12 months

Employed pre-stroke and returned to work

Actions correspond with hospital provider recommendations (warfarin, antihypertensive, antiplatelet, lipid-lowering, and diabetic medications)

Actions correspond with hospital recommendations

Normalized EQ-5D

Change in EQ-5D score from 3 to 12 months

3 &12 mo.

12 months

3 &12 mo.

12 months

3 &12 mo.

3 &12 mo.

3 &12 mo.

3 &12 mo.

12 months

Death and disability Composite outcome 12 months


Soon we’ll have clearer evidence of what services for which patients…

But how do we support them along the journey back home?


A look at care across the continuum…

STROKE TRANSITIONS IN CARE



Most Common Trajectories or Patterns of Care

There were 3,016 unique care patterns in the 120 days after an acute ischemic stroke


Discharged to Short-term Inpatient

Post-acute Care

24.1% Inpatient Rehabilitation Facility or Unit (N=37,064) 27.0% Skilled Nursing Facility (N=41,457)

5.3% IRF only

19.9% IRF +

HH

16.0% IRF +

OP

8.4% IRF +

SNF

30.5% SNF only

19.0% SNF +

HH

11.5% SNF +

OP

8.0% IRF +

HH + OP

6.2% IRF +

HH + Readmit

5.8% IRF +

SNF + HH

+ SNF or

+ HH

After Readmit

21.0% SNF +

Readmit

5.2% SNF +

HH + Readmit

+ SNF or

+ HH/OP

After Readmit

+ SNF

After Readmit



Discharged from the Hospital to the Community

14.9% Home Health

(N=22,875)

7.1% Outpatient

Rehabilitation (OP)

(N=10,982)

26.9% No Post-acute

Care (N=41,397)

52.6% No Post-acute

Care (no readmission and alive at 120 days)

63.2% Home Health only 10.1% HH + OP

77.0% OP

Rehabilitation Only

20.8% HH + Readmit

+ HH or

+ SNF

After Readmit


?

Involvement of

Primary and

Specialty Care?

27.4% Readmitted after hospital d/c without postacute care

20.0% Died after hospital d/c without post-acute care

A Critical Intervention Point

General Population

Population

At-Risk

The Transition to

Post-Acute Care

Acute

Care

Living in Community

Post-Acute

Care &

Rehab

Living in LTC




Critical Intervention Points for Stroke Survivors

Transitions

Acute

Care

Living in Community

Post-Acute

Care &

Rehab

Living in LTC


Gaps Identified By Observation, Provider and Patient Reports, and Research

Stroke Patients’

Needs

Hospital Discharge

Planning

Rehabilitation

Expertise


Transitional

Care

Interventions

G

A

P

Stroke Patients’ and

Caregiver’s Needs at

Home

Community-based

Care

Rehabilitation

Expertise

Transitions are a National Priority

• HHS Triple Aim: Better Care, Better

Health, Lower Cost

• HHS Priorities = National Quality

Strategy: Efficiency, population/public health, clinical effectiveness and processes, care coordination, patient and family engagement, patient safety

• CMS: The right care for every person every time

• Partnership for Patients: Reduce HAC by 40% and readmissions by 20%


Stroke Readmission:

Opportunity for Improvement

• National readmission rate:

13.8%

• Hospital riskstandardized readmission rate

(RSRR) range:

9.1%-20.6%


30

Shifting and Narrowing the Curve – How?


What is effective for stroke survivors?

TRANSITIONAL CARE

INTERVENTIONS


“the set of actions designed to ensure the coordination and continuity of health care as

patients transfer between different locations or different levels of care within the same location”

TRANSITIONAL CARE

Coleman et al., J Am Geriatr Soc 2003;51(4):556-7.


Transitional care is…

• Supportive of patients during handoffs

• A time-limited service

• Focus on continuity

• Commonly led by a nurse (more than 50% of interventions summarized in systematic reviews were nurse-led)

• An emerging key factor in care coordination


Why is this important?

Poorly executed or discontinuous health care transitions increase the risk of medical and medication errors, poor patient outcomes, caregiver stress, and unnecessary services



There are Many “TOC” Models

GRACE

BOOST

TCM

Which Intervention?

Core Interventions in Evidence-Based Transitional Care Models

Interventions RED CTI

Evaluation/risk assessment

Medications reconciled & plan confirmed X X

Patient education (with teach-back) on:

Diagnosis (daily)

Completed tests & appropriate follow-up

“Red flags” and response to problems

X

X

X

X

X

Patient education on medication management

Discharge plan

Written discharge plan or personal record

X

X

X

X

X

X

Discharge plan reconciled with national clinical guidelines X

BOOST

X

X

X

X

X

X

TCM

X

X

X

X

X

Bridge

X

X

X

GRACE*

X

X

INTERACT*

X

X

Appointments made for clinician follow-up, services , tests

Appointments to be scheduled by patients

X

X

X X X

N/A

Discharge summary (transition record) sent to postdischarge providers

Documented receipt of information by next provider

X X X

Telephone follow-up with patient to ID / resolve problems

In 2-3

Days

X

X

In 3

Days

X

In 2, 30 days

X

X

N/A

Home visit

Transitional care point person(s)

Facilitated engagement of patients, families, providers across episode

X X

X

X

X

X

X

X

N/A

*GRACE is a community-based model; INTERACT is a nursing home-based models


Evidence of Effectiveness?


KNOWLEDGE GAPS


Knowledge Gaps

1. Do these work for stroke patients?

2. Which strategies? (each intervention is multicomponent)

3. Do we replicate these interventions? Adapt locally?

Integrate strategies from different interventions?

4. Which transition or handoff?

5. For what period of time?

6. For which patients?


Transitional Care for Stroke: Roots in Policy

Wave 1: Heart Failure, Pneumonia,

Myocardial Infarction

Proposed Wave 2: Stroke, Chronic

Obstructive Pulmonary Disease

National Health

Reform: Reduce hospital readmissions

2012 Guidelines International Network

2012 International Stroke Conference

2013 International Association of Gerontology and

Geriatrics

Disseminated internationally


CDC commissioned a systematic review

Do we have the evidence we need?

Do these work for stroke patients?

Very few of the nationally promoted care transitions models included stroke patients.

Of those that did, none presented findings for stroke patients.




Team based approach including caregivers to return stroke patients home earlier but with continued rehabilitation of similar intensity and duration to inpatient care

EARLY SUPPORTED

DISCHARGE


ESD Components

• Patient identified in acute care (or inpatient setting)

• Discharged earlier

• Home visit within 24 hours of hospital discharge

• Goal-driven and patient-specific rehabilitation delivered in the home

• Services provided 4 x day (ESD phase), 6-7 days week for up to 4 weeks and then reducing to weekly visits by the point of exit (at most 4-6 weeks)

• Different levels of engagement with stroke specialist

(neurology)


Models of ESD

1.

Stand-alone acute outreach ESD only

– Prevalent in denser populated urban cities and where there are large city hospitals

2.

ESD with community stroke/neurology team service

– In-hospital component hands off to a usually well established community-based rehab team partnering with neurology

3.

Integrated ESD within community stroke team service

– All the components of models 1 and 2, plus support workers for rehab every day & multiple visits a day for up to six weeks

4.

Integrated ESD within community neurology service

– Often extends beyond stroke but then requires advanced skill set; prevalent in less urban areas

5.

RECOVER trial

– Nurse facilitated and organized, caregiver delivered


Evidence for ESD

• Multiple randomized controlled trials

• Meta-analysis confirmed patients who received these services returned home earlier (shorter inpatient length of stay) and were more likely to remain at home in the long term (longer “home time”) and to regain independence in daily activities (reduced death and dependency).

– The best results with well organized discharge teams and patients with less severe strokes.

• International Consensus Guidelines and considered best practices in

UK and Canada

– Canada ESD: $132.9 million direct cost savings.

• In the U.S.?

– Failed and not feasible given payment model for services


Proposed US Model (Govt. focus = ↓ costs)

Reduce costs by

34%, saving $2.4 million over a 3 year period for

300 stroke patients

Reduce rehospitalizations

Reduce utilization of post-acute services (in skilled nursing facilities, inpatient rehabilitation, and multipe episodes of home health care)

Reduce long-term care nursing home placement

Improve patient functional status and reduce secondary complications of stroke

Improve selfmanagement of stroke, co-morbid chronic conditions and CV risk factors

Improve patient and caregiver satisfaction with post-acute stroke care

Implement and optimize uptake of Early

Supported Discharge as the new health care delivery model for postacute comprehensive stroke management

Integrate primary care with Early

Supported Discharge to improve access and transition care to community-based providers

Transition to community-based wellness and exercise programs, and case management as needed

“Task” shifting at

3 levels: rehab, primary and community care


Not Quite a Global Perspective

General Population

Population

At-Risk

Acute

Care

Living in Community

Post-Acute

Care &

Rehab

Living in LTC



Adapting ESD Globally

• ATTEND trial (Family-Led Rehabilitation after stroke in India)

• RECOVER trail (A randomized controlled trial on rehabilitation through caregiver-delivered

• nurse-organized service programs for disabled stroke patients in rural China)



What is appropriate for rural China?


The

Trial

A Randomized Controlled Trial on Re habilitation through C aregiver-delivered Nurseo rganized

Ser v ice Programs for Disabled Strok e Patients in

R ural China


52

RECOVER Collaborating Institutions


53

RCT Study Description

Intervention and Control

♦ Intervention Group:

In-hospital

• “Teach-back” on stroke recovery, risk identification, and management

• Task oriented training

• Joint goal setting

• Evidence-based discharge planning

Training Intervention

Physicians /

Rehabilitation Therapists

Nurse + Patient +

Family Caregiver

Nurses from

County Hospitals

Patients & familynominated caregivers

After hospital discharge

• Call or visit at 2, 4, 6 and 8 weeks

• Blinded researcher measures outcomes by phone at 3 mo. & in person at 6 mo.

♦ Control Group: conventional care


54

Hypotheses

Primary Hypotheses

•To improve physical function

Secondary Hypotheses

•To improve physical functioning

•To improve quality of life

•To reduce disability

•To reduce depression

Exploratory Hypotheses

•To relieve burden of caregivers

•To reduce hospitalization

•To reduce hospital length of stay & costs


Primary Outcome

•Barthel Index

Secondary Outcomes

•Functional Ambulation Classification

•EQ-5D

•modified Rankin Scale

•Patients Health Questionnaire-9

Exploratory Outcomes

•Caregiver Burden Index

•Re-admission and hospitalization

•Hospital length of stay and medical costs

55

Study Design

-

Patient Recruitment

Inclusion criteria

• Adults (≥18 years);

• Recent (<1 month) first-ever acute ischemic/hemorrhagic/undifferentiated stroke patients;

• Expected to survive to discharge from hospital with a reasonable expectation of 6 month survival (i.e. not palliative, no evidence of widespread cancer etc.);

• Residual disability (requiring physical assistance for core activities of daily living defined as a Barthel Index score of 80 or lower).

Exclusion criteria

• Unable to identify a suitable family-nominated caregiver for training and subsequent delivery of care;

• Unable to provide informed consent from both the patient (or by proxy) and the caregiver.


56

Pilot and Main Study Samples and Sites

Sites:

•Zhangwu County,

Liaoning Province,

•Qingtongxia County,

Ningxia Province

Pilot Study

• Number of patients: 80

20 (I) + 20 (C) x 2 sites

Main Study

• Number of patients: 200

100 (I) + 100 (C) (1/2 each site)


Qingtongxia

Zhangwu

57

Complementary Models

Transitional

Care

Telehealth

Early

Supported

Discharge

RECOVER

2.0


Meeting the Needs of Stroke Survivors and Caregivers Globally

Many possibilities for efficacy and/or implementation effectiveness trials

• Urban or rural

• Single or multi-component strategy

• Inpatient- or community-based or both

• GPs or nurses or community workers or trained lay people

• Mobile phones and ipads or centrally located computers

• Intervention(s) to focus on functional impairment, secondary prevention, or prevention of complications

• Patients with or without cognitive impairment

• Different levels of inpatient care

• Different levels of caregiver engagement


Why are we committed to this global research agenda?

• Improve the lives of stroke survivors

• Reduce the burden on informal (family) caregivers

• Improve adherence to evidence-based care

• Improve the quality of care

• Improve physician-nurse partnership in the care of patients with stroke, disability, and chronic illnesses

• Build rehabilitation nursing capacity as leaders for caring for people with disabilities and chronic illness


60


Improving Stroke

Outcome: It is going to take a village


THANK YOU!

Janet Prvu Bettger, ScD, FAHA janet.bettger@duke.edu

here - Health Services and Systems Research

Mind the Gap: Supporting

Successful Care Transitions and

Recovery after a Stroke

WHERE ARE OUR

INTERVENTION POINTS?

A Critical Intervention Point

A TREMENDOUS OPPORTUNITY

Who are we studying and how?

Outcomes from Claims Data

STROKE TRANSITIONS IN CARE

A Critical Intervention Point

Transitions are a National Priority

Stroke Readmission:

Opportunity for Improvement

Shifting and Narrowing the Curve – How?

TRANSITIONAL CARE

INTERVENTIONS

TRANSITIONAL CARE

Which Intervention?

Evidence of Effectiveness?

KNOWLEDGE GAPS

Evidence of Effectiveness?

EARLY SUPPORTED

DISCHARGE

Not Quite a Global Perspective

Evidence of Effectiveness?

What is appropriate for rural China?

RECOVER Collaborating Institutions

RCT Study Description

Intervention and Control

Hypotheses

Study Design

Patient Recruitment

Pilot and Main Study Samples and Sites

Why are we committed to this global research agenda?

Improving Stroke

Outcome: It is going to take a village

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