Transitions of Care for Stroke Patients

Abstract

The last 30 years have seen tremendous progress in primary and secondary stroke prevention in the United States with better control of hypertension, decreasing smoking rates, antithrombotic treatment for atrial fibrillation, use of statins, and blood transfusions for children with sickle cell disease. 1 In 1996, intravenous tissue-type plasminogen activator was approved for treatment of acute ischemic stroke, 2 and in 2014 to 2015, endovascular treatment of major arterial occlusion, primarily by stent retrievers, was demonstrated to result in better outcomes for patients with ischemic stroke when compared with patients treated with intravenous tissue-type plasminogen activator alone.3 During this same time period, the field of neurocritical care grew tremendously in terms of physician and nurse training, standardization of care, and technology. Finally, standardization and certification of primary and comprehensive stroke centers have improved the quality of acute stroke care and the use of secondary prevention medications when patients are hospitalized for acute stroke.4,5 These cumulative advances have resulted in the decline in stroke mortality rates from the third to the fifth cause of death in the United States. 6 The bulk of these advances have occurred in 2 settingsthe office of primary care physicians who manages stroke risk factors in persons with and without a prior stroke; and the acute care hospital. Yet, the stroke patient follows a complex path from first onset of symptoms to the years after the onset of stroke, and the transitions between the respective places of care along the path represent major challenges and opportunities. Transition From Place of Stroke Onset to Acute HospitalOne of the first major transitions of care is when emergency medical services (EMS) respond to a 911 call for a potential stroke. EMS personnel assess the patient at the site of the event with input from family or other witnesses to see whether a stroke has occurred. After assessment, EMS has to transport the patient to a hospital for treatment of their potential stroke. Unlike trauma patients, where there is a defined process of triage to various levels of hospital care based on severity of the trauma and prior certification of hospitals regarding level of care, there is no such triage process for stroke patients. Legislation in several states and a policy statement from the American Heart Association (AHA) recommend that patients with a possible acute stroke be taken to a primary or comprehensive stroke certified hospital, 7 but current triage of patients to a given hospital is not based on severity of the stroke.Why is this important? Stroke severity is strongly associated with the presence of large artery occlusions in patients with ischemic stroke, 8 which are most effectively treated with rapidly administered endovascular therapy at regional comprehensive stroke centers. Also, patients with severe hemorrhagic stroke are best cared for in centers with experienced neurocritical care units. 9 Thus, ideally, patients ...

Estimates and Temporal Trend for US Nationwide 30-Day Hospital Readmission Among Patients With Ischemic and Hemorrhagic Stroke

“…Second, it is also possible that an emphasis on improving postacute transition of care (TOC) has accounted for some of this decline. 16 Multiple regional and local initiatives are under way to improve hospital discharge processes. 17 , 18 , 19 , 20 , 21 However, there remains considerable lack of standardization in TOC models across the nation for patients with stroke, and the overall influence of TOC improvement on stroke-related readmission remains to be systematically demonstrated.…”

The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial

“…Comprehensive post-acute services for stroke require bridging hospital-based acute care with expanded care teams for rehabilitation, primary care management, access to community resources, and caregiver support. Early supported discharge and other transitions of care processes may improve functional outcomes, but uncertainty remains as to the best method to manage stroke patients as they transition to home [26]. The CMS is setting new directions and reimbursements for value-based care for chronic conditions.…”

“…An effective, post-acute care model is needed given the significant impact of stroke on public health, the high risk and complexity of these patients early after discharge, and the strain on caregivers [26, 27]. Currently the U.S. lacks a standard to require hospitals to coordinate community-based follow-up visits with primary or specialty care [26].…”

“…Currently the U.S. lacks a standard to require hospitals to coordinate community-based follow-up visits with primary or specialty care [26]. The variation in availability, access, referrals, and effectiveness of post-acute stroke medical and rehabilitative care leads to significant gaps in the stroke system of care [28].…”

Regional Variation in 30-Day Ischemic Stroke Outcomes for Medicare Beneficiaries Treated in Get With The Guidelines–Stroke Hospitals

“…34,43 Finally, transitional care programs vary widely across the country 44 and could be an ideal target to improve ischemic stroke outcomes. 45 While our study was limited to select in-hospital processes of care measures, data on hospital discharge practices and the presence of programs designed to improve transitional care could account for some of the unexplained variation in outcomes. Future work should seek to confirm whether these factors explain observed variation in outcomes and identify other factors not considered in these analyses.…”