Reducing Stroke Readmission Through the Implementation of Telehealth

Abstract

Practice Problem: Readmission occurs frequently among patients with stroke and because of this, the Centers for Medicare and Medicaid Services (CMS) have imposed programs to reduce 30-day readmissions among hospitals. The health care system must respond with transition of care, especially during the period of recent stroke to improve patient outcomes. PICOT: The PICOT question that guided this project was among patients with a recent diagnosis of stroke (P), what is the effect of a telehealth appointment with a nurse practitioner (NP) for post discharge follow-up (I), compared to a standard face-to-face clinic appointment (C), on 30-day readmissions rates (O), within two months (T)? Evidence: Stroke is the fourth leading cause of death and has a readmission rate of 14%. Past studies have demonstrated the effectiveness of telehealth in treating patients outside of the hospital setting, which suggests the potential of telehealth on post-discharge follow-up care. Intervention: To assess the impact of telehealth on 30-day readmission rates, stroke patients received a telehealth follow-up phone visit by a NP within ten days of being discharged to home. Outcome: Data was collected from participant’s electronic health records (EHR) and discharge databases from October 13 to November 13, 2020. Among participants, the implementation of telehealth visits demonstrated a reduced readmission rate of 6.25% for stroke patients. Conclusion: Telehealth is an effective, sustainable, and widely implementable strategy to provide post-discharge care to patients. This study outlined a framework to further analyze the effectiveness of telehealth visits in reducing 30-day readmission rates among stroke patients. REDUCING STROKE READMISSION 3 Reducing Stroke Readmission Using Telehealth Healthy People 2020 strives to address the lack of access to healthcare, particularly among certain populations challenged by lack of insurance, cost, cultural competence, proximity to hospitals, and other social issues posing barriers to access (Healthy People 2020, 2019). The inability to readily access healthcare creates a foundation for negative outcomes impacting the rate of recovery, quality of life, and financial strain on hospitals that manage such populations. Programs developed by the Centers for Medicare and Medicaid Services (CMS) such as the Hospital Readmissions Reduction Program (HRRP), which aim to improve quality by impacting reimbursement rates for hospitals with high 30-day readmission rates, further impose strain among hospitals. Recent events created an increased demand to connect with patients using telehealth by bringing access to medical care wherever the patient is located (Serper & Volk, 2018). The purpose of this evidence-based practice (EBP) project was to illustrate the implementation of telehealth in the outpatient care setting as a modality to increase access to care among patients who recently sustained a stroke and to reduce readmission rate within 30-days post discharge. This project previewed EBP and literature review to support the use of telehealth among stroke populations and identified a theoretical framework to support the implementation of a successful change project. This paper discussed evidence search strategies used and findings for common themes. The practice setting, overview, recommendation, methodology, and evaluation were also included with a plan for project dissemination. Significance of the Practice Problem Readmission rates represent a key quality indicator of healthcare services (Fisher et al., 2014). In the United States (US), avoidance of 30-day readmission is a top priority because of HRRP and federal guidelines under the Affordable Care Act of 2010 (Gai & Pachamanova, REDUCING STROKE READMISSION 4 2019). Measurement of 30-day readmission to assess the quality of care was also a recommendation by the Agency of Healthcare Research and Quality (AHRQ) in the United States (Ross et al., 2017). Hospitals received financial penalties if they demonstrate high recurrence of 30-day readmission rates (Vahidy et al., 2017). Readmission occurs frequently among stroke survivors (The Global Burden Disease [GBD] Lifetime Risk of Stroke Collaborators, 2016). In the past, stroke has been a leading diagnosis in readmission accounting for 25% of incidents during the first year of diagnosis (Gorelick, 2019). Poston (2018) found a 12% unplanned readmission within one month of discharge among patients with ischemic stroke. According to California Health and Human Services (CHHS), the national readmission rate is 14% for stroke patients, thus, these readmissions resulted in a cost of about 500 million dollars to CMS (Gorelick, 2019). Unplanned readmissions among patients with stroke happen due to various medical reasons one-month postdischarge such as kidney and urinary infection, pneumonia, health failure, and electrolyte imbalances (Nouh et al., 2017). Readmission is also attributed to patients missing their follow up appointments due to debility and fatigue after hospitalization (Boehmn et al, 2015). With a movement towards shortened length of hospitalization, patients with stroke are discharged with limited inpatient rehabilitation programs (Hicks & Cimarolli, 2018). Stroke is a debilitating event requiring close medical follow up to mitigate further complications (Driessen et al., 2016). Globally, stroke incidence affects 15 million patients annually and represents the second largest cause of death following heart disease (Gorelick, 2019). According to the GBD study in 2016, stroke is the leading cause of disability worldwide with approximately 80 million survivors requiring post stroke care (World health Organization [WHO], 2018). Five million people REDUCING STROKE READMISSION 5 worldwide live with permanent disabilities from stroke (World Stroke Organization [WSO], 2016). Nationally, stroke comprises the fourth leading cause of death (Center for Disease Control [CDC], 2018). Annual statistics in the US show approximately 800,000 American adults have suffered from a stroke (WSO, 2016). The estimated cost of healthcare services, medicines to treat stroke, and missed days of work is estimated at $34 billion annually (CDC, 2019). Locally, the incidence of stroke is 80-90 people per 100,000. As part of a complex Los Angeles health care system, the identified health care agency directs a stroke system of care that manages stroke patients for both acute and rehabilitation needs. This safety net facility houses an inpatient stroke unit with 24 beds, sees an average of six discharges per week, and operates an outpatient medical home service with 120 unique patients served weekly (Rancho, n.d.). In comparison to the national readmission data, the Los Angeles health care system has an 18% readmission rate for patients with stroke who generally endure socio-economic disadvantages, such as lack of financial support to arrange for a clinic transportation or lack of familial support (Lacounty.gov). Patients with stroke are burdened with the sequela of long-term disability impacting mobility, loss of independence, income, or employment, with a lifetime cost of stroke per person of $105,000 (Johnson, Bonafede, & Watson, 2016; Terman et al., 2018). The average cost of hospitalization involving stroke is $23,000 and varies greatly by the type of stroke, diagnosis status, and co-morbidites, such as hypertension or diabetes (Wang et al., 2013). The health care system must respond with transition care, especially during the period of recent stroke, and complex care needs further complicate stroke-related disabilities (Terman et al., 2018). Providing telehealth as a follow up intervention after discharge offers a way to reduce readmission among patients with stroke (Hicks & Cimarolli, 2018). REDUCING STROKE READMISSION 6