Abstract NS19: A Bird’s Eye View: A System-Wide Approach to Reducing Stroke Readmissions
Background: In January of 2013, Aultman Hospital was selected among 500 hospitals nationwide to participate in the Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) Initiative. The hospital chose to participate using the stroke patient population during the acute hospital stay and services up to 90 days after hospital discharge. During the discovery phase, data was analyzed that helped to identify opportunities for stroke patients across the continuum of care.
Purpose: To identify areas of opportunity to reduce all-cause readmissions and to improve transitions of care across the continuum for stroke patients.
Methods: A multi-disciplinary steering committee came together to review the analyzed data and identify care coordination opportunities. Reviewed data included stroke patients from 2008 to current, with a strong focus on readmissions and complications of care. A care coordinator position was created to follow all Medicare stroke patients for 90 days following discharge. The position provides a consistent person that would ensure that individual needs are met across the continuum and possibly prevent readmissions. Several interventions have been initiated that have helped to prevent readmission to the hospital system such as: facilitation of visiting physician for home bound patients, obtaining therapy orders for patients post-discharge, medication counseling, referrals to physicians when appropriate, and providing family support.
Results: In 2012, the all-cause readmission rate for stroke patients was 8.8%. In 2013, the readmission rate for stroke patients was 9.4%. From January of 2014 to April of 2014, the readmission rate decreased to 9.0%. After implementation of the high risk care coordinator position in May of 2014, the readmission rate has decreased to 5.8%.
Conclusions: Throughout Aultman’s journey with the BPCI, common themes remain: the need for collaboration of services for stroke patients to ensure continuity of care and to streamline the encounter for the patient. Aultman’s BPCI for Stroke team was able to identify ways to reduce stroke readmissions, prevent complications of care for stroke patients, and reduce the overall financial impact to an overburdened public health system.
Author Disclosures: J.M. Brackman: None. K. Samblanet: None. A. McGee: None.
- © 2015 by American Heart Association, Inc.