Care Management Strategy Improves Lives of Stroke Patients

BACKGROUND

Stroke takes a devastating toll on those who experience it. On average, one American dies from stroke every 4 minutes with more than 795,000 deaths annually.¹For survivors, rehabilitation is notoriously difficult. Stroke is a leading cause of serious long-term disability,²中风患者第一年入院的比例从20%到27%不等。³

In 2013, Allina Health created a rehabilitation care coordination model within Courage Kenny Rehabilitation Institute to provide heightened support and better care management for high-risk patients with different conditions, including stroke—a common cause of hospitalization within the Allina Health System.

THE IMPORTANCE OF CARE MANAGEMENT FOR POST-STROKE PATIENTS

The needs of individuals who experience stroke are complex and challenging.

Upon discharge from the hospital, individuals may not realize maximum improvement due to factors such as missed appointments, non-adherence to medication, or delays in receiving outpatient therapies. It became clear to CKRI leadership that post-stroke patients needed strong care management during key transitions – after discharge from the hospital to the home, and after discharge from rehabilitation to outpatient care and community support services. It also believed that stroke survivors would benefit from increased education about their condition and care needs.

最后，还需要大量的数据(但不容易获取)来进行中风后功能测量，例如伯格平衡量表、伯格跌倒风险和曼恩吞咽能力评估的数据。

CARE MANAGEMENT AND BETTER DATA IMPROVE STROKE RECOVERY OUTCOMES

CKRI ultimately created a holistic program for stroke survivors that delivers seamless care across inpatient, outpatient, and community support services, enabled by access to comprehensive data. Strong leadership spearheaded the program’s implementation, including a Stroke Advisory Committee that regularly met to oversee the process. Other components included:

• 增加教育。CKRI为提供者和患者创建了几个中风后项目。这些活动包括为患者和家属制作的教育视频、同行访客、故事分享，以及专门为年轻中风患者量身定制的小组。
• Assigned care manager.Secured grant funds to pay for this role, filled by an experienced registered nurse. She is a critical member of the care team, helping individuals and their caregivers understand and navigate through what can be a complex delivery system. She is available from diagnosis through treatment, working with a care guide and a social worker who collaborate in managing the patient’s support needs.
• Strengthened relationships between inpatient teams and rehab care support services.All clinical care and rehabilitation services, such as occupational, speech, and physical therapies, are now carefully coordinated to assure stroke care is delivered when and where it needed, most efficiently.
• Data analytics platform.CKRI also implemented a data warehouse and analytics platform from Health Catalyst, a project that integrated clinical, demographic, cost, claims and patient functionality data from across the enterprise. This gave clinicians powerful new capabilities:
  • Can now identify and target high risk patients as soon after admission as possible for coordinated stroke care
  • Prove value of care management model through improved outcomes (Berg Balance Scale, Berg Fall risk, Mann assessment of swallowing ability, missed appointments, etc. for post stroke patients that were supported by the care manager)
  • Measure financial impact of care management model; for example, how preventative measures save the system money
  • Measure and improve patient satisfaction

RESULTS

在一年内，阿丽娜通过节约成本，最重要的是，通过挽救实际生命，证明了这种新的中风护理模式的价值。

• $350,000 saved over a one-year period.These savings were realized through the care coordinator’s efforts resulting in reduced or eliminated need of services that would otherwise have been required by this patient population, including:
  • 7% reduction in hospitalizations
  • 7% reduction in hospital days
  • 46% reduction in emergency department visits
• Saved and improved stroke patient lives.
  • 每1000次中风死亡率从36降低到0。根据2015年400例患者的病例量，出院后前6个月死亡人数减少了14人。
  • 继发性中风减少8%。Patients with care management services experienced an 8% less chance of a secondary stroke within 180 days of discharge.

“We have seen an exciting evolution in care for stroke patients, from care in “silos” to highly integrated and managed care across the entire continuum. Better outcomes shows this new model works.”

–Diane Chappuis, MD,
Medical Director of Stroke Rehabilitation, Allina Health

WHAT’S NEXT?

With such impressive results, Allina plans to expand the Stroke Care Management Program and improve outcomes for more patients. Incidentally, this program has laid the groundwork for learning how to produce these outcomes at the lowest possible cost—an essential capability in the new era of value-based reimbursement.

REFERENCES

1., 2.Mozzafarian, D., Benjamin, E.J., Go, A.S., Arnett, D.K., Blaha, M.J., Cushman, M.,…Turner, M.B.Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–322.
3.Sacco, R.L., Hauser, W.A., & Mohr, J.P..Hospitalized stroke in blacks and Hispanics in northern Manhattan. Stroke. 1991;22:1491–1496.

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