Abstract 67: Using Patient Activation to Transition Patients from Hospital to Home
Background: The community hospital as a part of a large health care system participates in the Ohio Coverdell Stroke Program. The Coverdell Goals are to improve the quality of patients’ care transitions, reduce avoidable complications, and support the reduction of patients’ unnecessary readmissions. The purpose of the project was to evaluate if the tools, Patient Activation Assessment (PAA), Personal Health Record (PHR), and the Patient Activation Measure (PAM) improve transitions from the Inpatient Rehabilitation Facility (IRF) to home, without patients experiencing an unnecessary readmission. The nurse used the tools to teach patients stroke fundamentals and self-management strategies.
Methods: The population consisted of all stroke patients discharged home from the IRF over twelve months (n=177). The intervention was patient stroke education based on the PAM and the PAA scores while utilizing the PHR. The nurse taught stroke fundamentals within the structure of the PAA four pillars directed to the patient and the care advocate.
Results: The project goal to transition stroke patients safely from the IRF to home with a decrease in unnecessary readmissions was met. The patients in the project experienced a 50% decrease in readmissions in less than thirty days from patients discharged the previous year (n=172). The team compared stroke patients' PAM and PAA scores prior to discharge instruction, after instruction, and then prior to discharge to home with a significant improvement in the PAA scores P < 0.005. Patients with a PAA score of 7 and above were discharged to home. Similarly patients with a PAM of 40 and above were discharged home.
Conclusions: The initial three month phase of the project demonstrated an improvement in the PAM and PAA scores. There was a trend of increased patients’ activation scores related to discharge disposition, and a decrease in readmission rates. Therefore the use of the PAM, PAA, and PHR was incorporated into the IRF nursing practice for all stroke patients. The nurses focus their stroke teaching on patients with lower activation scores with the goal of increasing the scores and improving patients’ ability to return home and avoid an unnecessary readmission. The results over one year mirror the original three month pilot project.
- Patient education/teaching psychosocial aspects
- Stroke recovery
- Disease management
Author Disclosures: M. McLaughlin Davis: None.
- © 2015 by American Heart Association, Inc.