Stroke is one of the leading causes of death and disability in the United States. It takes a toll physically, mentally, emotionally and financially on its victims. Stroke affects an estimated 795,000 people each year in the United States, and there are over 4.4 million stroke survivors in this country. It is one of the 10 highest contributors to Medicare costs, and the elderly are at highest risk for hospitalization due to stroke and transient ischemic attack (Lichtman et al., 2012). Our hospital cares for more than 3,000 stroke patients on an in-patient basis each year (Cleveland Clinic, 2016).
Preventing stroke readmissions is a high priority for stroke teams. Stroke readmissions occur in nearly one-quarter of stroke patients annually, and these create a significant burden on an already overwhelmed healthcare system. Stroke readmissions are primarily non-neurological, and the most common cause is infection, including chest and urinary tract infections. Coronary artery disease and heart failure are strong predictors of readmission, although the readmissions are not primarily cardiac related. Discharge planning, including strong communication between the inter-professional team and the primary care physician, is essential to prevent readmissions. The team must establish a reliable link prior to discharge to allow the patient and the family to contact the primary physician and continue the post-discharge plan. Home follow-up visits including physical therapy significantly reduce readmissions (Bhattacharya, Khanal, Madhavan & Chaturvedi, 2011; Lichtman et al., 2012).
Acute rehabilitation provides hospital-level care to stroke patients who need intensive rehabilitation care provided under direct supervision of a physician (Davis, 2019). Hospitalized stroke patients with acute rehabilitation recommendations should be transitioned to acute rehabilitation as soon as they are medically stable, in order to achieve the best possible outcome (Johnson et al., 2015). Due to a myriad of reasons, the initial hospitalization can be extended for an unnecessary number of days.
Every unnecessary day in the hospital contributes to a delay in patients receiving the rehabilitation services that they need, and to high costs that affect patients, families, health systems and health plans (Johnson et al., 2015). This financial burden is added to the already high costs of rehabilitation, long-term care and loss of workforce (Fassbender et al., 2017).
Daily interdisciplinary rounds (IDR) are recommended for all inpatients; they are essential for stroke patients. Effective interdisciplinary communication is vital to providing safe, timely and quality transitions of care for stroke patients. Physicians, nurses, therapists and other disciplines as appropriate participate in the interdisciplinary rounds. Each member provides a unique perspective to the patient’s plan of care, identifies problems and creates strategies to resolve them. The patient and or their caregiver should be the central planner for where and how the patient is transitioned. IDR prevent errors and improve interdisciplinary communication (Lancaster, Kolakowsky-Hayner, Kovacich, & Greer-Williams, 2015).
A stroke patient’s journey is unexpected, long and unpredictable (Johnson et al., 2015). Strokes affect people of any culture, age, gender and socioeconomic status. Many stroke patients suffer permanent and debilitating functional, physical, cognitive, linguistic, visual and psychosocial issues (Ouellette et al., 2015). Rehabilitation is key. The goal of rehabilitation is to restore lost functions as much as possible, prevent complications and improve the quality of life (Ziejka et al., 2015).
A multidisciplinary approach through IDR engages different healthcare disciplines with diverse perspectives that identify problems and create strategies to resolve them. Case managers leading IDR can effectively identify and investigate the reasons for unnecessary delays in care transitions and an increased length of stay for hospitalized stroke patients.
Patients suffering from a stroke, with complex short- and long-term needs will benefit from effective IDR and a subsequent care plan. “Multidisciplinary teams lead to better patient outcomes, reduced hospital costs, and reduced time in the hospital” (Johnson et al., 2015).
Case managers play an integral role in leading the experience of care while decreasing the cost. They possess the skills that are necessary to work with interdisciplinary teams to help support best practice standards for patients with complex disease processes. These core competencies align with the practice standards for case management, which are assessment, planning and implementation based on evidence and practice (Jennings, 2019).
Case managers and the multidisciplinary team understand that the characteristics of stroke patients include quality of life and functional loss. According to Wang & Langhammer (2017), quality of life can be perceived differently by various cultures; however, regardless of culture, stroke patients can suffer from similar functional losses. Many stroke patients suffer permanent and debilitating physical, cognitive, linguistic, visual and psychosocial issues (Ouellette et al., 2015). Rehabilitation is key to restoring lost functions as much as possible, preventing complications and improving quality of life (Ziejka et al., 2015). Therefore, moving the patient to acute rehabilitation as soon as the patient is medically stable is a critical step.
Clinical documentation supports patient care, improves clinical outcomes and enhances inter-professional communication (Pagulayan et al., 2018). It enhances the care of the patients, in that the combined data from each discipline can be synthesized to support moving quickly to acute rehabilitation, or the next recommended level of care.
Healthcare policy, regulations and governing bodies have a significant impact on the relevancy of healthcare practice. Effective care coordination with a multidisciplinary team improves the care of hospitalized stroke patients and reduces costs by providing a focused individual care plan for each patient. The individual care plan is contained within the recommended care path for stroke patients, which is supported by CMS evidence-based standards of care and practice.
Case managers play an integral role in leading change and driving improvements in the quality and experience of care. Within case managers’ scope of practice are competencies such as managing high-risk individuals with the aim of preventing or delaying adverse outcomes; recognizing and maximizing opportunities to increase the quality of care; communicating relevant information to the patient and inter-professional healthcare team across the care continuum; and applying effective teamwork and collaboration skills to overcome identified barriers to produce quality and effective patient outcomes (AAACN, 2016).
Case managers in collaboration with the inter-disciplinary team, the patient and the family can minimize the time from stroke to acute rehabilitation through optimizing the care path to accommodate the patient’s individual needs and goals. The care plan is effectively documented in the electronic medical record with the substantiation of the need for physical rehabilitation in an acute setting that can clearly be understood by the acute rehabilitation admissions team and the health plan.
American Academy of Ambulatory Care Nursing. (2016). Scope and standards of practice for registered nurses in care coordination and transition management. Pitman, NJ: Author.
Bhattacharya, P., Khanal, D., Madhavan, R., & Chaturvedi, S. (2011). Why do ischemic stroke and transient ischemic attack patients get readmitted? Journal of the Neurological Sciences, 307, 50-54.
Cleveland Clinic. (2016). Mobile Stroke Unit. Retrieved from https://my.clevelandclinic.org/health/treatments/17242-mobile-stroke-unit
Davis (2019). Intensive inpatient rehabilitation: optimal path for stroke patients. AHC MEDIA; Hospital Case Management, 27(10).
Fassbender, K., Grotta, J. C., Walter, S., Grunwald, I. Q., Ragoschke-Schumm, A. & Saver, J.
(2017). Mobile stroke units for prehospital thrombolysis, triage, and beyond: benefits and challenges. Lancet Neurol, 16(3), 227-237. doi: 10.1016/S1474-4422(17)30008-X.
Jennings, A.L. (2019). Understanding the nurse case management role across the health care continuum: reducing gaps and easing transitions in care. Alabama Nurse, 45(4), 10-11.
Johnson, J., Smith, G. & Wilkinson, A. (2015). Factors that influence the decision-making of an interdisciplinary rehabilitation team when choosing a discharge destination for stroke survivors. Canadian Journal of Neuroscience Nursing, 2015; 37(2), 26-32.
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Lichtman, J., Leifheit-Limson, E., Jones, S., Wantanabe, E., Bernheim, S., Phipps, M., Goldstein, L. (2010). Predictors of hospital readmission after stroke A systematic review. Stroke, American Heart Association Journal, November, 2525-2533.
Ouellette, D. S.; Timple, C.; Kaplan, S. E.; Rosenberg, S. S.; Rosario, E. R.; Predicting discharge destination with admission outcome scores in stroke patients. NeuroRehabilitation, 37(2), 173-179. DOI:10.3233/NRE-151250
Pagulayan, J., Eltair, S. & Faber, K. (2018). Nurse documentation and the electronic health record: Use the nursing process to take advantage of EHRs’ capabilities and optimize patient care. American Nurse Today, 13(9), 48-54.
Ziejka, K., Skrzypek-Czerko, M. & Karłowicz, A. (2015). The importance of stroke rehabilitation to improve the functional status of patients with ischemic stroke. Journal of Neurological & Neurosurgical Nursing, 2015; 4(4), 178-183. DOI:10.15225/PNN.2015.4.4.6
Wang, R. & Langhammer, B. (2017). Predictors of quality of life for chronic stroke survivors in relation to cultural differences: a literature review. Scandinavian Journal of Caring Sciences, 32(2), 502-514. DOI:10.1111/scs.12533