A Focus on Stroke Care After Discharge

By Matt Phillion

With Stroke Awareness Month in May, it’s a great time to look at not only how we identify stroke symptoms and handle emergencies, but also the importance of care for stroke patients post-discharge. One in four stroke patients are discharged from the hospital within four days of their stroke and are often left stranded without a thorough care plan.

As more and more of patient care is being shifted into the home, these at-home plans can’t be successful without addressing the comprehensiveness of the care plan.

Pam Duncan, PhD, founder and CEO of Care Directions, retired professor of neurology and adjunct professor of internal medicine with Wake Forest University School of Medicine, notes that the healthcare industry has a long way to go with how it handles stroke patients after they leave the four walls of the hospital. Her organization is using a technology called StrokeCP to capture social and functional determinants of health for stroke patients at the point of care.

“There’s huge gaps, and those gaps are getting wider and wider,” she says. “If we look at stats from the CDC, while mortality from stroke has decreased by 80% with acute interventions, disability related to stroke has increased by 70%.”

Adding to this challenge is a tremendous pressure for patients to be discharged immediately from acute care facilities, with most stays lasting only three or four days.

“There’s an increased pressure to discharge patients directly home, but there’s often a need for more comprehensive inpatient rehab services,” says Duncan “On the other hand, there are payer incentives for them to go directly home, and that in itself offers tremendous challenges.”

Stroke patients are unique, Duncan notes, because you often have a patient who already has chronic illnesses and now has acute new onset disabilities.

“Most patients who are discharged quickly have had a mild stroke rather than a severe one, and those patients are often most at risk. They’re discharged prematurely without a full appreciation of what their new deficiencies might be,” says Duncan. “These might be mild cognitive deficiencies or depression for example, and there is not enough time in that brief stay to thoroughly evaluate the patient for those residual disabilities.”

Comprehensive doesn’t mean comprehensive care

It’s important to distinguish, Duncan notes, that while comprehensive stroke centers exist, and can provide treatments such as tPA and endovascular thrombectomy, but are not necessarily set up to follow the patient after discharge.

“We have insufficient follow up,” says Duncan. “I’d draw a parallel of how you’d never go into a comprehensive cancer center and then say goodbye, whereas in a stroke center you’re discharged immediately. So what does that mean? We have to be able to follow these patients with transitional care.”

Part of the challenge is simply a lack of personnel.

“There aren’t enough neurologists to follow the patients: the comprehensive stroke centers are managed by neurologists, and they are managing patients for acute care and potential intervention,” says Duncan.

There just isn’t enough capacity to keep up, she notes.

“Some successful programs have begun using physician extenders to alleviate this,” says Duncan. “And oftentimes, the neurologist will recommend the patient go back to their primary care to be seen, but the reality is we have wait times for primary care, PCPs are leaving the profession, and they’re not set up to manage complex patients. Even for mild stroke cases there’s complex underlying conditions like diabetes and hypertension. And many patients may not have the cognitive ability, resources, or physical health to manage their care.”

CareDirections has worked toward addressing that point of discharge, because often it’s not until they leave the facility that a patient realizes they’ve got a new challenge, problem, or limitation they aren’t prepared for.

“We assess and interview the patient and caregiver and find out what the range of deficits are they’re experiencing, both physical and cognitive,” says Duncan. “We also want to understand the drivers that inhibit the patient or caregiver as they manage the patient’s health. Stroke patients are discharged with an average of five new medications, and 20% can’t afford their meds when they are discharged. How do we begin to understand the social and functional drivers that are their inhibitors to managing their health?”

To that end, the platform enables a quick and efficient assessment of the patient as well as follow up calls or visits to examine their barriers to success, their deficits, and from there, generate a care plan individualized for the patient and prioritized for their needs.

“It’s about bringing in tech as a solution to help healthcare systems manage their patients,” says Duncan. “And most importantly it allows the patient or caregiver to communicate with the provider.”

Help the people who are doing the helping

An important aspect to the technology is making it available and usable by caregivers to empower them to more easily provide care to their loved ones.

“A personal example: healthcare systems expect everyone to manage their care electronically through a patient portal,” says Duncan. “Right now, I’m trying to manage my husband’s care, and even for me, someone who works in the field, interacting with these portals can be difficult. But with the right tech, we can push the right data and communicate. We can individualize care plans based on the caregiver’s ability to manage it.”

It is critical that the caregiver is well-informed and aware of the patient’s needs and treatments and empowered to help them.

“Our approach is to get the patient and the family centered so they can manage this journey,” says Duncan.

This can help with the sort of self-monitoring and post-discharge care many patients fall behind on, she says. Take blood pressure for example: with over 80% of strokes caused by high blood pressure, less than a third of patients can control their blood pressure after a stroke.

“And then you start changing medications, which can be expensive and complicated to manage—even people with mild cognitive impairment have difficulty with this,” says Duncan.

Patients want to know their health after discharge matters, Duncan says.

“During our research in North Carolina, we had someone say: ‘I was Life-Flighted in but parachuted out without a parachute,’” she says. “Patients can be confused and overwhelmed by a new disability and this can easily lead to depression, another common post-discharge condition. We want to empower them and make sure they know to have hope as they move toward a healthy recovery.”

In the long run, Duncan says, we need payers involved. But there can be real financial benefits to addressing post-discharge care for stroke patients even above and beyond it being the right thing to do medically and ethically.

“If you don’t manage the patient, there will be another stroke,” she says. “Payers have to be motivated to come to the table for this.”

Preventable readmissions need to be discussed. Duncan notes that 75% of stroke patients fall within three to six months of discharge, and these falls can lead to injuries and readmissions.

“Falls are the number one factor that causes patients to go to ED,” says Duncan. “It’s not rocket science. The follow-up may not generate enough revenue, but the benefit to the health system is in decreased readmissions, increased efficiency of care, increased satisfaction, and decreased patient leakage. But most importantly it’s about the safety of the patient.”

To have optimal recovery, you need to have optimal care, says Duncan. She would like to see something along the lines of a national campaign to educate the public about where they can go for the resources they need, and even a hotline of some kind where caregivers can reach out for advice as they care for a loved one recovering from a stroke.

“We are in a transformative time, and technology should not be a barrier. It should be a facilitator,” says Duncan. “I don’t think the system is broken, but I think it’s fragmented and there are perverse incentives now for care. When you look at the stats, this is a population that needs help. We need to take care of them after they leave the building.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.