Abstract 23: Reducing Stroke Readmissions Utilizing a Home Care Based Transitions Coaching Program

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Background: The Center for Medicare and Medicaid Services (CMS) has instituted utilization of all-cause, unplanned 30 day hospital readmissions following discharge for ischemic stroke as part of the Hospital Inpatient Quality Reporting Program. While readmission reduction following stroke is a hospital imperative, there is minimal evidence on stroke-specific readmission reduction programs.Purpose: We sought to reduce 30 day readmissions following ischemic stroke through utilization of an established care transitions program in collaboration with our institution’s affiliated home care agency.Methods: Our institution’s home care agency has reduced readmission rates in the general medical population utilizing the Coleman Care Transitions Model©. This model incorporates motivational interviewing in visits prior to hospital discharge, with a home visit 24 to 48 hours after discharge, and by telephone at least weekly by a trained transitions coach. The coach ensures understanding of medications, follow up visits, and recognition of red flag symptoms. A one year pilot program for stroke patients utilizing this established program was initiated in October 2015. Basic stroke training was provided for all coaching staff. Quarterly readmission rates for 1 year prior to the intervention and 6 months following were analyzed.Results: During the first 6 months of the pilot program 18.2% of patients discharged with a diagnosis of ischemic stroke qualified for and completed the coaching program. Of those in the program 3.3% were readmitted. Overall, there were 15 readmissions in 13 patients, 85% of whom did not receive transitions coaching services. The readmission rate in the year prior to intervention was 7.8%, in the 6 months following 4.5%. These findings represent a 42.7% overall reduction in readmissions (p = 0.06) and a treatment effect of 1.7.Conclusions: Utilizing the Coleman Care Transitions Model© led to a meaningful reduction of hospital readmissions for patients with ischemic stroke in this pilot program. In an area in which readmission reduction has proven challenging, expanding the availability of a home care based program for specific patient populations may be an effective strategy.

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