Background: Readmissions can negatively impact patients, families and health care organizations. Readmission penalties have resulted in focused efforts around discharge planning, patient engagement and transitional care.
Purpose: We hypothesized that development of a transitional care intervention 'bundle' could decrease our stroke readmission rate.
Methods: A literature search related to readmission reduction strategies for stroke patients and a transitional care gap-analysis were completed. The literature review defined at-risk patients as over 80 years old with cardiovascular comorbidities, dysphagia, diabetes and high stroke severity. Additional variables included a lack of stroke-validated readmission predictive models, variable causes for readmissions and different insurance and databases used. A retrospective review of our 30-day readmitted stroke patient records from November 2012- October 2013, showed our patients were most often low stroke severity, low risk of mortality and readmission based on an internal risk assessment tool called PRISM, most often discharged home, younger than reported in the literature, and most often returned within a week from discharge. We noted there was vast variation between the literature findings and our stroke readmissions. The literature review included best practices for non-stroke related readmissions. The gap-analysis showed we were not doing many best practices at our organization related to transitional care. We created a set of stroke-specific interventions including: scheduled follow-up appointments based on PRISM score, new patient education and teach-back tools, then targeted patients discharged home. Implementation was complete in July 2014.
Results: January 2014-June 2014 readmissions were 12%. July 2014- December 2014 readmissions decreased to 8%. Using a 2 sample t-test, a comparison of these time periods showed a significant improvement: P = 0.046.
Conclusion: Standardizing transitional care by implementing strategies focusing on stroke patients discharged home has resulted in a statistically significant reduction in readmissions. The reason for the differences between the organization's readmission profile and that discussed in the literature remains unclear.