Fragmentation & Contemplation: Transfers & Transitions of Care

1. Fragmentation & Contemplation: Transfers & Transitions of Care Presented at 2018 NorthEast Cerebrovascular Consortium October 26th, 2018 Joan Breen, MD

2. Disclosures: Joan Breen MD • Financial Disclosures: none • Unlabeled/unapproved use: none

3. Learning Objectives • Participants will: • Understand challenges facing community dwelling stroke survivors and their caregivers • Understand components of a novel community based multidisciplinary stroke rehabilitation program • Understand how this novel program addresses the multiple complex medical, rehab, psychosocial, care transition and vocational needs of stroke survivors • Understand positive outcomes of stroke survivors treated in this novel outpatient stroke rehabilitation program • Recognize the disease prevention and health promotion benefits this novel outpatient program can promote in this population

4. Burden of Stroke Cost in United States $33.9 billion: (2012-2013 average annual cost) $17.9 billion: direct medical cost $16 billion: indirect cost • Stroke: United States • Incidence: 795,000 yearly • 610,000 (77%)first attacks • 185,000(23%) recurrent • Global Prevalence 2013: • 25.7 million • 5.2 million first attacks <65 years • Leading cause of adult, long term disability Heart Disease and Stroke Statistics-2017 update

5. Stroke Survivorship • Good news!!! • Increasing survivors d/t advances in rapid treatment in acute care, screening, and diagnosis • More survivors returning home • Not so good news!!! • Once home, NO dedicated stroke specific OP programs • No survivorship care plans

6. Survivor Challenges Once Home: “I am an Island……” • Complex medical care is paused • Once Home; Hospital level medical management ends • Confusion exists: medications, CV risk factors, BP & other previously provided care instructions; importance of medical follow-up apts • Fluctuations in BP and other medical conditions • New stroke related functional deficits • Falls, changed; ADL, IADL, driving, working, identity role • Confusion regarding duration for ongoing recovery and rehab options • Only 31% of survivors receive OP rehab (CDC, 2007) • Lack of Psychosocial Support • Insurance and financial questions/limitations • Decreased knowledge of community based supports • Depression, Social Isolation, Caregiver Concerns

7. “ARS Q# 1” Potential challenges facing stroke survivors once home include all of the following except: • A. Fluctuations in Blood Pressure & other medical conditions • B. Decreased risk of recurrent stroke • C. Depression • D. Falls • E. Insurance & Financial burdens

8. Systems Challenges Once Home • Limited Data • Patient centered outcomes not reported (work, drive, community re-entry) • Standardized functional assessment not routinely utilized • No dedicated outpatient stroke Rehab programs • Treated in general OP with lack of stroke specific care • Disease management not included in general OP Rehab (BP,DM, diet, exercise) • No Survivorship Care Plans: Standardized Acute Hospital & Inpatient Rehab Care Plans do not Exist in Outpatient • Fragmented transitions/info transmission between care settings • Lack of community/care systems support • Stroke not generally recognized or treated as chronic illness

9. Bridging the Gap Patient Centered One Stop Shoppingaddressing: • New/changed medical conditions/CV risk factors • Rehab needs • Psychosocial support • Care transitions and coordination • Accessing community based services • Vocational & Community re-entry needs

10. Unique Patient Centered OP Program • Developed at Whittier Rehabilitation Hospital, Haverhill, MA in 2011 • Varying patient population (Cultural, socioeconomic, geographic) • Achieved Joint Commission Certificate for Disease Specific Outpatient Program (2013,2015) • Non-research based, operates w/in limitations of insurance benefits

11. Program Design: Patient Centered Care • Dedicated Multidisciplinary Team combining MD/NP cardiovascular/stroke care alongside outpatient rehabilitation • Combines features of inpatient and cardiac rehab models • Small treatment and support groups promote peer interactions, encouragement and participation • Addresses special needs of stroke survivors • Multiple complex medical issues • Rehabilitation • Psychosocial • Care transition and follow ups • Vocational needs

12. Program Design (cont) • Standardized assessments routinely utilized • Valid and reliable • Administered & reviewed monthly • Performance Improvement (PI) projects to optimize rehab efforts

13. Unique to Program : Medical • Neurologist & NP involved in daily medical and rehab issues • Regular NP led CV education (AHA Life’s Simple 7) • Risk factor assessment & action plan • BP assessment & self monitoring • Medication reconciliation and compliance • Teach life long skills to foster independence with health maintenance, accessing medical care & community re-entry to promote ongoing recovery

14. Unique to Program: Adapt Rehab • Dedicated rehab team w/ weekly team meetings • Individual PT, OT, ST and small group sessions • Family team meetings • PT/OT monitor BP • Standardized assessments utilized • Return to driving program • Incorporate innovative Technology (robotics, WI, Dynavision, Augmentive Communication devices)

15. Unique to Program:Emphasis on Care Coordination/Transitions • Communication with healthcare providers: medical status, medication, psychosocial and rehab issues • Developing strategies to increase patient independence with medical care, care transitions, healthy lifestyles, community re-entry • Coordinating community-based support services (NILP) • Assisting with transportation, insurance, financial resources • Developing transitions of care with state vocational rehab services for return to work

16. ARS Q #2: Some components of this novel stroke rehab program include: • A. OT, PT, ST • B. MD/NP involvement • C. Individual & group treatments • D. Free Cigarettes • E. A, B, & C

17. Unique to Program • Focus on “Back to Life” patient centered goals including return to work, driving, and community re-entry

20. Program Outcome Highlights • Patients of varying ages, stroke severity, stroke type demonstrate improvements in rehab outcomes, including endurance, balance, functional status, stroke knowledge, return to work & driving • 44% of those working prior to stroke return to work (additional 9% work capable) • Patients beginning program > 6 months prost-stroke achieve equal or greater improvements in rehab outcomes camped to those beginning < 6 months

21. Return to Work Summary • 44% returned to work • 35% were aphasic • 55% mRS3 and 10% mRS4 on admission • 75% ischemic and 23% hemorrhagic stroke • 90% of patient returning to work also returned to driving • 75% continued rehab after returning to work with 47% of these being aphasic

22. Case Study: NC • 34 yr. old generally healthy, African American male bus driver • married with 2 children, smoker • Sudden onset Right Hemiplegia & global aphasia • Admitted to Comprehensive Stroke Center w/ NIHSS of 19, CTA w/ left M1 clot, early changes in left basal ganglia • Received IV TPA followed by successful intra-arterial recanalization, neurologic improvement with F/U NIHSS of 5 • Work-up revealed severe cardiomyopathy w/ EF 18%, LV thrombus as stroke etiology; hyper-coagulopathy, other W/U negative • Discharged home 1 week post stroke w/ new cardiac restrictions & meds

23. Case Study: NC • Began Program 1 month post stroke with: Mild aphasia, right weakness, decreased coordination, deconditioning, & afraid • Did not know his medications; never took meds before & didn’t want to take meds now • Decreased understanding of cardiac precautions, CHF diet, signs & symptoms of stroke • Still smoking; Not monitoring BP, HR, weight • Orders without Cardiac Parameters • Occupation: Bus driver of handicapped persons for the county • Disability paperwork problems • Became bradycardic and HR irregular with PT exercises, NP followed up with CHF clinic, Holter ordered, no AF found, treadmill walking resumed

24. Case Study: NC-Initial Interventions Communication/Care Coordination w/ multiple providers: • NP Phoned Cardiomyopathy clinic for Cardiac Parameters &current Med list • Faxed our CV Orders to Cardiomyopathy NP • Individualized stroke & deficit education • Intensive CV risk factor education (AHA) & printed materials • Med reconciliation/education w/typed chart • Pocket med & health card • CV exercise program w/ BP self monitoring • Rehab Journey Memory/Education binder • Return to work addressed • Vision assessment & return to driving program • OT & ST therapies • Referral to Vocational Rehab and community services

25. Case Study: NC - Outcomes 7 Months: • Returned to work @ same company but in different job • Completed pre-driving program, passed in car road competency exam & returned to driving • Self Monitoring BP, HR & Weight • Not Smoking; Exercising regularly • Compliant with medications • Continues with Cardiomyopathy clinic &other specialty care 1 Year: • Passed State DMV requirements /Commercial license road test &successfully returned to prior job as bus driver

26. Case Study: TG • 53 years old electrician • HTN, Hyperlipidemia, smoking, overweight—non compliant w/ meds • Developed confusion, aphasia, mild right facial weakness • Admitted w/ BP: 160s/90s; NIHSS: 2 • Neuroimaging showed Left anterior-medial Thalamic Lacunar infarct • (Echo & CTA neg) • D/C to home in 48 hours on Statin, ASA, ACE, nicotine patch • No referral for rehab

27. Case Study: TG • Had f/u w/ new Neurologist @ 2 weeks who released patient to return to work • Family initiated referral to NRP because of concerns over patient “not at baseline” & “didn’t think he could do his job” • Began program 3 weeks post stroke w/Evals: • NIHSS: 1 (mild aphasia); BMI: 35.9 • ST RBANS Scores: Immediate memory & Attention: extremely low; Language: Low Average • Poor deficit awareness (felt he could be back @ work) • Inconsistent med adherence • Unable to describe his CV risk factors or medications

28. Case Study: TG • Interventions & Outcomes: • Communication/Care coordination w/ PCP • Individualized stroke & deficit education • Intensive CV risk factor education (AHA Life’s Simple 7) • Med reconciliation/education, chart, pocket card • CV exercise program w/ BP self monitoring • Rehab Journey Memory/Education Binder • Vision assessment & return to driving program • Return to work program initiated w/ gradual return to full-time prior job • Successfully working; taking meds; not smoking; improved lifestyle

29. Case Study: RA • 70 yr old married retired mailman; Jazz musician promoter • HTN, Hyperlipidemia; Medical care & Medication avoider • Developed gradual onset of Left hemiplegia • Admit BPs >200/100; head CT neg; CTA brain only neg; carotid U/S & cardiac echo neg • Brain MRI recommended • Started on BB, ASA, Statin • Inpatient rehab x 2 weeks w/ gradual improvement in strength & D/C to home on Statin, ASA, ACE, BB

30. Case Study: RA • Began outpatient Program 6 weeks post-stroke • PCP did not know patient had suffered a stroke & had no info (d/c summaries, med list) • BP’s remained 150s/70s- 190/100; • Patient still doubtful that he had suffered a stroke as head CT neg & he was improving (could now walk, etc) • Poor understanding of diet, CV risk factors • Wife administering meds • Not self monitoring BP

31. Case Study: RA • Interventions & Outcomes: • Communication/Care coordination w/ PCP • Ongoing frequent phone calls re stroke w/u, hospital d/c instructions, meds, BP & assistance w/ apts • F/U Brain MRI ordered showing Centrum Semi-Ovale Lacune • MRI reviewed w/ patient w/ improved acceptance of stroke diagnosis • Individualized stroke deficit & Intensive CV risk factor, BP self monitoring education—Involvement of wife • Med reconciliation/education, chart, pocket card • Rehab Journey Communication/Education/BP monitoring Binder • Vision assessment & return to driving program • BP, weight, diet, lifestyle improving; med compliant; aware of recurrent stroke risk/sx; continued care coordination w/ providers

32. Keys to Promote a Successful Recovery • Multidisciplinary Team, MD/NP involvement in daily medical and rehab issues • Family-Team meetings enhance individual patient treatment & care transitions • Small treatment & support groups • Patients demonstrate readiness to learn at this time in this setting • Providing care coordination to address financial, behavioral, caregiver/family issues • Developing strong care transitions with individual healthcare providers, community services, and state vocational rehabilitation services • Incorporating patient-centered goals of return to work & driving are strong motivators • Hospital wide support for program

33. Recovery can be a successful journey! • Despite many varied challenges, stroke patients are motivated to recover • Additional research is needed to: • Understand mechanisms supporting stroke patients’ return to work and other patient-centered goals • Develop more cohesive systems of community-based care for stroke survivors

34. Successful Implementation of this program type will improve life after stroke Support Groups Successful monitoring, treating, and managing chronic diseases e Weekly Team Meetings Home blood pressure monitoring Check. Change. Control. Healthy Living After Stroke

35. Meet the Team: Thank You to all our Hard Working Patients!!

36. References 1. Breen, J, Andrusin, J, Ferlito, T, et al. AHA Guidelines Nurse Practitioner Cardiovascular Risk Education Program Delivered in Outpatient Stroke Rehabilitation Program Leads to Increased Independence with Medications, Self Blood Pressure Monitoring, Improved Blood Pressures, and Rehabilitation Outcomes, Stroke. 2014;45:ATP127. 2. Breen, J, Andrusin, J, Ferlito, T, et al. Community Based Outpatient Stroke Rehabilitation Program Achieves Excellent Outcomes Including Return to Work, Driving, Improved Blood Pressure Control, and Other Rehabilitation Outcomes, Circ Cardiovasc Qual Outcomes. 2015;8:A203. 3. Breen, J, Andrusin, J, Ferlito, T, et al. Patients Beginning Community Based Outpatient Stroke Rehabilitation Program More Than 6 Months Post Stroke Achieve Equally Excellent Outcomes as Sub-Acute Patients, Stroke. 2016; 47: AWP195 4. Breen, J, Andrusin, J, Ferlito, T, et al. Characteristics of Stroke Patients Treated in a Community-Based Interdisciplinary Outpatient Rehabilitation Program Who Return to Work, Stroke. 2016; 47: AWP 147 5. AHA Heart Disease and Stroke Statistics—2017 Update Circulation. 2017;135:00–00. DOI: 10.1161/CIR.0000000000000485; 3/7/2017. 6. Breen, J, Andrusin, J, Ferlito, T. et al. Characteristics and Estimated Rehabilitation Costs of Stroke patients treated an Interdisciplinary Outpatient Rehabilitation Program who return to work. Stroke. 2017; 7. Winstein CJ, Stein J, Arena R, et al. AHA/ASA Guidelines for Adult Stroke Rehabilitation and Recovery. A guidelines for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2016;47XXX-XXX. DOI: 10.1161/STR.0000000000000098.

37. ARS Q # 3: How Can We Work Together to Develop More Comprehensive Care Systems to Address the Many Varied Needs of Stroke Survivors After Hospital D/C? • THANK YOU !!!!