Mind the Gap: Supporting Successful Care Transitions and Recovery after a Stroke

1. 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

2. Presentation Outline • Burden of stroke • Systems perspective of stroke care • Evidence gaps • Care models for improved recovery from stroke

3. Projected Deaths by Cause for High-, Middle- and Low-Income Countries Other NCDs Cancers CVD

4. Burden of Stroke: DALY Leading cause of serious, long-term disability in the US Johnston et al. Lancet Neurol 2009;8:345-54

5. 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 self-care 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

6. 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

7. Once someone has a stroke… Where are our intervention points?

8. Stroke System of Care and Transitionsin Care

9. A Critical Intervention Point The Transition to Post-Acute Care General Population Living in Community Post-Acute Care & Rehab Acute Care Population At-Risk Living in LTC Olson DM, Prvu Bettger J, Alexander KP, et al. AHRQ 2011

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

11. 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 longer-term outcomes?

13. Services After Acute Care

14. Care Following the Acute Hospitalization

15. …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

16. Specific Aims (what we promised we would do … at a high level) • 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) • Compare high intensity rehabilitation (provided in inpatient rehabilitation facilities; IRF) and low intensity rehabilitation (provided in skilled nursing facilities; SNF) on several outcomes • Compare outpatient (OP) rehabilitation and home health (HH), and how either are better than no rehabilitation. • Compare PCP and neurologist follow-up on outcomes

17. 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 participatingin the Get With The Guidelines-Stroke program.The person had to be a Medicare fee-for-service beneficiary for health care. Some were in a prospectivecohort study, AVAIL.

18. Outcomes from Claims Data

19. Patient Reported Outcomes

20. Soon we’ll have clearer evidence of what services for which patients… But how do we support them along the journey back home?

21. A look at care across the continuum… Stroke transitions in care

22. Most Common Trajectories or Patterns of Care There were 3,016 unique care patterns in the 120 days after an acute ischemic stroke

23. Most Common Trajectories or Patterns of Care

24. Most Common Trajectories or Patterns of Care ? Involvement of Primary and Specialty Care?

25. A Critical Intervention Point The Transition to Post-Acute Care General Population Living in Community Post-Acute Care & Rehab Acute Care Population At-Risk Living in LTC Olson DM, Prvu Bettger J, Alexander KP, et al. AHRQ 2011

26. Critical Intervention Points for Stroke Survivors Transitions Living in Community Post-Acute Care & Rehab Acute Care Living in LTC Olson DM, Prvu Bettger J, Alexander KP, et al. AHRQ 2011

27. Gaps Identified By Observation, Provider and Patient Reports, and Research Stroke Patients’ Needs Hospital Discharge Planning Rehabilitation Expertise Stroke Patients’ and Caregiver’s Needs at Home Community-based Care Rehabilitation Expertise Transitional Care Interventions G A P

28. 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%

29. Stroke Readmission: Opportunity for Improvement • National readmission rate: 13.8% • Hospital risk-standardized readmission rate (RSRR) range: 9.1%-20.6%

30. Shifting and Narrowing the Curve – How?

31. What is effective for stroke survivors? Transitional care interventions

32. “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.

33. 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

34. 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

35. There are Many “TOC” Models Care Transitions RED TCM GRACE STARR BOOST BRIDGE INTERACT

36. Which Intervention?

37. Evidence of Effectiveness?

38. KNOWLEDGE GAPS

39. Knowledge Gaps • Do these work for stroke patients? • Which strategies? (each intervention is multi-component) • Do we replicate these interventions? Adapt locally? Integrate strategies from different interventions? • Which transition or handoff? • For what period of time? • For which patients?

40. Transitional Care for Stroke: Roots in Policy Wave 1: Heart Failure, Pneumonia, Myocardial Infarction Proposed Wave 2: Stroke, Chronic Obstructive Pulmonary Disease 2012 Guidelines International Network 2012 International Stroke Conference 2013 International Association of Gerontology and Geriatrics

41. 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.

42. Evidence of Effectiveness?

43. 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

44. 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)

45. Models of ESD • Stand-alone acute outreach ESD only • Prevalent in denser populated urban cities and where there are large city hospitals • ESD with community stroke/neurology team service • In-hospital component hands off to a usually well established community-based rehab team partnering with neurology • 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 • Integrated ESD within community neurology service • Often extends beyond stroke but then requires advanced skill set; prevalent in less urban areas • RECOVER trial • Nurse facilitated and organized, caregiver delivered

46. 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

47. Proposed US Model (Govt. focus = ↓ costs) “Task” shifting at 3 levels: rehab, primary and community care

48. Not Quite a Global Perspective General Population Living in Community Post-Acute Care & Rehab Acute Care Population At-Risk Living in LTC Olson DM, Prvu Bettger J, Alexander KP, et al. AHRQ 2011

49. 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)

50. Evidence of Effectiveness? What is appropriate for rural China?