Discharge and Community Based
Follow-up Care for Acute Stroke
Sarah Kain MSN RN PCNS
Lindsay Walker MSN CRNP
Acute Stroke Management Conference
Friday April 21, 2017
From Acute Care to Community Based Care
Sarah Kain RN MSN PCNS
Acute Stroke Management Conference
Friday April 21, 2017
Now the Real Work Begins…..
Objectives
1. Integrate the post discharge needs of the acute stroke patient
and the barriers to follow up care
2. Explain how severity of illness and intensity of service act as
drivers of a discharge plan: observation vs. inpatient
3. Discuss the important role of efficient testing & therapy
evaluations (speech, physical, occupational)
4. Establish appropriate discharge dispositions based on identified
patient care needs, external factors and medical complexity
5. Support optimal patient and family satisfaction
Discharge Planning begins on Day of Admission!
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Review of patient’s medical record/multidisciplinary input
Introduction patient/family to role of care management
Discussion with patient and family about planned length of stay
Identify patient and family roles in discharge planning
Engage in dialogue with patient/family about preference of discharge
disposition.
Criteria for Admission
• InterQual® level of care criteria
• McKesson Health solutions/division of McKesson technology (owner)
• Developed by clinical research staff: physicians, registered nurses, other
health care professionals with advanced degrees/ care management
certification and accreditation
• Reviewed and validated by a national panel of clinicians/medical experts
throughout the US
• Synthesis of evidence-based standards of care, current practices and
consensus from licensed specialists and/or primary care physicians
Interqual ® Stroke Definitions
• CNS infarction: brain, spinal cord or retinal cell death caused by ischemia
• Ischemic Stroke: episode of neurological dysfunction caused by focal
cerebral, retinal or spinal infarction
• Silent CNS infarction: imaging evidence of CNS infarction without
neurological dysfunction
• ICH: collection of blood within the brain parenchyma or ventricular
system not caused by trauma
• Stroke caused by ICH: rapidly developing clinical signs of neurological
dysfunction related to the collection of blood
Interqual ® Stroke Definitions (con’t)
• Silent cerebral hemorrhage: imaging evidence of a collection of chronic
blood products within the brain parenchyma, subarachnoid space or
ventricular system with no evidence of neurological dysfunction
• SAH: Bleeding into the subarachnoid space
• Stroke caused by SAH: rapidly developing clinical signs of neurological
dysfunction related to bleeding into the subarachnoid space
• Stroke cause by cerebral venous thrombosis: infarction or hemorrhage
into the brain, spinal cord or retina as a result of thrombosis of a cerebral
vessel
InterQual® acute level of care criteria provides support
for determining medical appropriateness of hospital
admission, continued stay and discharge
InterQual ® Criteria addresses 4 Levels of Care:
 Observation (assessment q 6-24 hours)
 Acute ( assessment q 4-8 hours)
 Intermediate (assessment q 2-4 hours)
 Critical (unstable/assessment q 1-2 hours)
Interqual ®
Levels of Care
•
Observation
– Hemodynamically stable
– Requires 6-24 hr. of tx or
assessment pending decision
regarding need for additional
care
– Excludes ED observation or
holding area
– Outpt. Billing status
– Observation notification
– State vs. Federal laws
• Acute
– Hemodynamically stable who
require tx, assessment or
intervention Q 4-8 hrs.
– Inpt. Billing status
Observation level of care
(TIA /stroke recrudescence)
Intensity of service
Severity of Illness
CT/MRI
Neurological deficit
exacerbation
Paralysis
e
Blindness
Diplopia
Echo
Carotid Doppler
Cardiac
monitor
Neuro
assessment
6x/24 hours
anticoagulant
administered
or
contraindicated
Observation/
MOON letter
Outpatient
billing status
Usually 23
hours or less
Episode day 1 (Severity of illness): Acute
• Stroke
• Finding: neurological deficit: aphasia, ataxia, blindness, diplopia,
dysarthria, dysphagia, mental status change, paralysis, paresis, partial
or total gaze palsy, sensory deficit
• Image finding by CT scan or MRI: cerebral thrombosis (actual or
suspected), focal ischemia (actual or suspected)
• Hemorrhage
Day 1 (Intensity of Service ): Acute
• Neurological assessment q 3 hours
• IV medication: Both
• Anti-arrhythmic, anticonvulsant, antihypertensive, beta blocker,
calcium channel blocker, diuretic, insulin, vasoactive, inotrope
• Administration: greater than one
continuous and monitoring q 3-4 hours
• Bolus q 3-4 hours
• Titration q 3-4 hours and monitoring
• Oxygen saturation ≥ 40% ≤ 2 days
Documentation
Accuracy required to support the following:
- Continued hospital stay
- Health insurance coverage
- Hospital payment
- Clinical progress vs. decline
- Planned disposition
Documentation
• Recovery Audit Contractor (RAC)
– Program created through the Medicare Modernization Act of
2003 (MMA)
• Purpose: to identify and recover improper Medicare payments
paid to healthcare providers under fee-for-service (FFS)
Medicare plans
• Medicare/Medicaid fraud results in billions of dollars in
government and taxpayer costs
• Fines can be triple the cost of payments received for fraudulent
claims
What is Audited and by Whom
• Severity of illness: MRI reports, paralysis, blindness, speech
deficits, other neurological deficits
• Intensity of service: vital signs/neuro checks q 2 hours/IV
medication /cardiac monitor
Audits are conducted by physicians, physical therapists, RNs, care
managers and other members of
the health care profession
Assessing Discharge Disposition Needs
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Severity of illness/intensity of service
Type of stroke: review of MRI; discussion with physician
PT/OT /Speech/medical complexity/ cost of care
Insurance: self pay/Medicare/Medicaid/out of state
Home situation: care givers, # of steps, finances
Home/ home care, SNF, acute rehab, LTAC, personal care, assisted
living; PASSIR; Options; Freedom of choice; IMM; medicare.gov
• Equipment needs: wheelchair, walker, versamode, shower chair
• Transportation to next destination (ambulance transport/car)
American Stroke Association (ASA)
Recommendations for Stroke Rehab
• American Heart Association/American Stroke Association (AHA/ASA)
scientific statement
• First issued guidelines in 2016 regarding adult stroke rehab and the
need for intensive multidisciplinary treatment
• Before leaving the hospital, patients and caregivers should receive a
formal falls-prevention program to prevent accidents at home
• Whenever possible, initial rehab should take place in an inpatient
rehab facility, rather than a nursing home
Post Discharge Fall Prevention
• Participation in structured programs on preventing falls prior to hospital
discharge
• Education regarding changes to make the home environment safe
• removing throw rugs
• improving lighting
• Minimizing the fall risk resulting from side effects of medication
• Safely using assistive devices such as wheelchairs,
walkers and canes
Discharge
• Home alone/ no needs
• Home/Home Care
– RN/PT/OT/Speech/social work/home health aid
• Department of aging services (based on finances)
• Equipment needs: wheelchair, hospital bed, walker, cane, lifeline,
• Personal care/Assisted Living
• SNF: therapy < 3 hours; 1 skilled need/ med cost/target/restraints?
• Acute rehab: therapy > 3 hours; must have 2 skilled needs/medical
complexity (examples of skilled needs, PT, OT, Speech)
• LTAC (long term acute care); MA Pennsylvania does not pay for
• Hospice
Engaging the patient and team in medical readiness criteria for
discharge by utilizing a whiteboard discharge pathway
Discharge when….
Criteria for Medical Stability & Discharge
MEDICAL
Vital signs stable
Speech/physical, occupational therapy evaluations completed
Symptoms controlled/cardiac rhythm stable
Appropriate anticoagulation arranged if needed
Labs reviewed and testing completed
TRANSITION
Needs evaluated by social worker/care manager
Diet established and education completed
Home oxygen evaluation completed if indicated
Care giver confirmed and education completed
Depression screen completed
Follow up prescriptions and lab work ordered
DISPOSITION
Pharmacy medication coverage confirmed; pre-authorization obtained if needed
Home care and equipment ordered
Expected d/c
Expected destination
Date confirmed:
Surprise!........Your being Discharged!
• Patient /team has not planned the discharge 24 hours in advance
• Unprepared (for discharge) patient and team
• Negatively impacts readmissions and the patient
experience/satisfaction
Why is Patient Satisfaction so Important?
• Beginning Oct. 1, 2012 the Centers for Medicare & Medicaid
Services (CMS) began withholding hospital’s Medicare
reimbursement based on quality performance
• 30% of the decision derived from how well hospitals score on
the Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) survey
• Patients often speak about their hospital experience to others
• Patients will come back if they need another hospital encounter
Resources
Feigin V.L., Norrving B., George M. G., Foltz J. L., Roth G. A., & Mensah G.A.
(2016). Prevention of stroke: a strategic global imperative. Nat Rev
Neurol 12(9):501–512.
McKesson Corporation. (2016). Interqual level of care criteria 2015. Ireland:
Business Care connectivity.
Medicare. (2017). What medicare covers. Retrieved from
https://www.medicare.gov/sign-up-change-plans/decide-how-to-getmedicare/whats-medicare/what-is-medicare.html
Weinstein, C.J. (2016). In-patient rehab recommended over nursing homes for
stroke rehab. American Heart Association & American Stroke Association.