Reducing readmissions for stroke patients benefits both the patient and the hospital. This is something hospitals are actively working on: Among all patients with stroke, 30-day hospital readmission declined by an annual mean of 3.3% between 2010 and 2014.*
iVantage Health Analytics asked hospitals what they are doing to reduce readmissions for stroke patients. See "Reducing Readmissions for Stroke/TIA Populations" for detailed information from 18 responding hospitals. Here are some of the things they are doing:
- Providing Patient Education/Advocacy: Use a Patient Navigator. Provide education on lifestyle changes, disease management.
- Performing Robust Rounding/Monitoring: Multidisciplinary rounds include Case Management. Social Work, PT/OT, physician, APP to coordinate on care management and discharge planning for each stroke/TIA patient. Case Managers on the floor flag high risk patients and provide an in-depth approach to care. Schedule follow up appointments with the neurologist and primary care provider. Interdisciplinary rounds start the discharge plan process on day 1. Complete discharge phone calls for all stroke/TIA patients between 2 and 14 days following discharge. Utilize a Patient Care Coordinator to schedule follow up physician appointments and conducts phone calls up to 20 days post-discharge.
- Using Order Sets: Use stroke order sets to start the workup on admissions.
- Actively Working with Nursing Homes: Developed a Skilled Nursing Home Collaborative, reducing readmissions from the nursing home to the hospital. This Collaborative meets on a quarterly basis; hospital leaders attend site visits bi-annually; quality measures are monitored.
- Placing Social Workers in the ED: Staff the ER with Social Workers for those complex patients that need a lower level of care (not requiring hospitalization).
Are these strategies working? Yes! Most agreed that these measures are working well.
Learn more from peers about stroke -- see our Stroke Knowledge Community. Contact us if you'd like to join!
*August 17, 2018. doi: 10.1001/jamanetworkopen.2018.1190.