Q&A: Advice for preventing readmission of stroke survivors
Q: How as a case manager can I help stroke patients reduced the likelihood of readmission?
A: Stroke affects an estimated 795,000 people each year in the United States, and there are over 4.4 million stroke survivors in this country. It is one of the 10 highest contributors to Medicare costs, and the elderly are at highest risk for hospitalization due to stroke and transient ischemic attack (Lichtman et al., 2012). Stroke readmissions are primarily nonneurological. The most common cause of stroke readmission is infection, including chest and urinary tract infections. Coronary artery disease and heart failure are strong predictors of readmission, although the readmissions are not primarily cardiac related. Stroke readmissions occur in nearly one-quarter of stroke patients annually, and these create a significant burden on an already overwhelmed healthcare system (Bhattacharya, Khanal, Madhavan, & Chaturvedi, 2011).
Discharge planning, including strong communication between the interprofessional team and the primary care physician, is essential to preventing readmissions. The team must establish a reliable link prior to discharge to allow the patient and his or her family to contact the physician with the postdischarge plan. Home follow-up visits, including physical therapy, significantly reduce readmissions (Bhattacharya, Khanal, Madhavan, & Chaturvedi, 2011; Lichtman, Leifheit-Limson, Jones, Wang, & Goldstein, 2012; Amarasingham, et al., 2013).
For more information, see Case Management Guide to Population Health. Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.