Background and Issues: The transition of stroke patients home is complex. Assessment of functional status and coordination of healthcare and support services while engaging patient and family to be active participants in secondary prevention is essential in preventing stroke recurrence. Readmission rates for stroke patients are also high. Reductions in stroke readmissions must target unresolved problems at discharge and the quality of immediate post-hospital care.
Purpose: The purpose of the Community Paramedic program is to reduce stroke readmissions. An additional goal is to identify key areas which may contribute to poor patient outcomes or readmission and develop and implement action plans for their prevention.
Methods: Use of a community paramedic transitional care model is an innovative approach to reduce readmissions in the stroke population. Using the Model for Improvement, an interprofessional team developed a transitional care program focusing on patient-centered care delivery, and on reducing readmissions and adverse outcomes. Use of The National Transitions of Care Coalition’s essential interventions categories, the program addressed: medication management, transitional planning, shared accountability, provider engagement, patient and family engagement and education, follow-up care, and information transfer.
Results: Despite a 13% increase in stroke patient volume from 2014 to 2015, the program realized a statistically significant reduction in readmission rate (10.7% to 8.51%; p = .045, α =.05) in 2015 and has sustained the reduction through 2016. This reduction represents 21 avoided readmissions in the stroke population with cost avoidance of at least $210,000.00. The decrease in readmission rate is well below both the goal and stretch goals of 5% and 10% reduction in stroke readmissions.
Conclusion: The impact of integrating Community Paramedics into a transitional care program coordinated through Stroke Navigators shows a significant impact on reducing 30-day readmissions. Replication in other patient populations and other counties may have a significant impact for both patients and hospitals focused on improving similar outcomes.