Follow-up Appointments after Stroke Hospital Discharge: Hospital-based Improvements to Bridge the Gap

Introduction: Stroke patients are at a significant risk of discontinuous care and consequently adverse events. The average length of stay for an acute stroke hospitalization in the United States is 4 days and 50% of patients are then discharged home. Follow-up with community-based providers is known to facilitate care continuity and reduce hospital admissions for other disease states. No standard of care or quality measure is in place for requiring follow-up appointments to be made for stroke patients. Practice Change Implemented: A one year regional quality improvement collaborative facilitated hospital-based improvements with discharge planning to improve the quality of stroke patient’s transition home from the hospital to include follow-up appointments scheduled prior to discharge. Aim: 85% improvement in the proportion of hospitalized stroke patients discharged home who had a follow-up appointment scheduled with a community-based provider (physician or advanced practice provider, general or specialty neurological care). Targeted Population and Stakeholders: Adult patients with an acute ischemic or hemorrhagic stroke, or transient ischemic attack admitted to 48 hospitals in a Midwestern region of the United States. Timeline: 12-month quality improvement collaborative from April 2013 to March 2014 (quarters 12=baseline; quarters 3-4=active improvement phase). Highlights: Hospitals participated in three all-site collaborative meetings, monthly webinars to share strategies and lessons learned, and received quarterly performance reports. Over 12 months there were 5,302 stroke patients discharged home. Compared to baseline, there was an 80.3% improvement in the proportion of patients with a follow-up appointment in quarter 4 of the collaborative (p<0.001). Improvement was greater for scheduled specialty care appointments (83%) than appointments with general or primary care (79%). International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117011 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Conclusions: Despite this improvement, more than 50% of stroke patients were still without a follow-up appointment prior to hospital discharge. Analysis of patient characteristics showed fewer appointments were scheduled in quarter 4 for patients discharged home who had a stroke type other than ischemic, were obese/overweight, or without a history of hypertension (p<0.05). There was no difference in scheduled appointments by age, stroke severity, or other co-morbidities. Discussion: Hospital performance with scheduling follow-up appointments improved significantly; however, there is room for continued improvement particularly with targeted patient sub-groups identified. Lessons Learned: System-level barriers at individual hospitals could be better addressed to facilitate continued improvement. Reported barriers to appointment scheduling included lack of dedicated hospital personnel to plan appointments with the patient and family, limited or no access to online or electronic appointment scheduling, and limited access to community-based clinic or office staff to schedule appointments. Weekend discharges were especially problematic without a shared information technology platform between inpatient and community based providers.