By: Tailar Johnson, OTD, OTR/L | August 8, 2024
A stroke can have long–lasting impacts, with 90% of survivors reporting at least one stroke-related health complication that can be a barrier to recovery and lead to hospital readmission¹. With one of the highest rates of Emergency Department utilization, stroke is considered to be among the most expensive chronic conditions². The burden of stroke on both survivors and the healthcare system, coupled with many preventable post-stroke complications, underscores the need for post-acute support that improves quality of life, reduces subsequent stroke risk, and decreases unnecessary hospital readmissions.
Kandu Health was recently highlighted in a publication titled “Feasibility of a Telemedicine-Based Principal Illness Navigation (PIN) Service for Complex Populations Following Hospital Discharge After Acute Stroke” in Stroke Clinician3, the official journal of the Association of Neurovascular Clinicians. The article outlines the use of outpatient PIN services to provide stroke support and navigation to survivors and care partners after hospital discharge. These services provide individualized support, education, care coordination, and management of post-acute stroke in an effort to improve outcomes and decrease hospital readmissions. This feature highlights the possible value and benefit of navigation services for better management and care of stroke survivors. Despite changes to reimbursement, including Centers for Medicare and Medicaid Services (CMS) coverage for PIN services and an increasing body of literature highlighting the need for post-acute stroke navigation, Kandu Health’s services remain an exception rather than a standard of practice.
Anne Alexandrov, professor of Nursing and Neurology at UTHSC Memphis and Program Director of Net Smart, discusses practical implementation strategies for implementing post-stroke navigation services.
The Recovery Gap in Post-Acute Stroke Care
While the literature is growing in support of navigation services for stroke patients, the data on PIN is still emerging. To develop best practices we must address current gaps in post-acute stroke care. “As an acute care practitioner we typically focus on rapid early treatment. It is eye opening when we hear from stroke survivors about their post-acute recovery experience,” said Alexandrov. To bridge these gaps, an increase in awareness is crucial, but it is only part of the solution. “As a stroke care community, it is important to support evidence generation to evaluate the effectiveness of PIN in this population. Developing robust evidence will allow us to make post-stroke navigation part of our future practice guidelines.” said Karen Seagraves, former Enterprise Vice President of Neurosciences and Executive Director of a Comprehensive Stroke Center.
Bridging the Gap
As post-acute stroke standards of care are developed in accordance with emerging evidence, collaboration between hospital systems, payors, accreditation agencies, industry leaders, stroke survivors, and care partners is needed to ensure that navigation programs, like Kandu, serve the needs of all stakeholders. “Delivering effective post-acute stroke care is a complex undertaking. It involves addressing the individual patient needs, providing condition specific education, and ensuring survivors have the tools and resources to follow their care plan. There is a tremendous patient need for Principal Illness Navigation”, Alexandrov explained.
Not only do patients need better post-acute support; so do hospital systems. To stay compliant with certification standards, hospitals require more effective patient follow-up for reporting quality metrics. Karen Seagraves, was able to shed light on certification compliance difficulties for hospitals in post-acute stroke, stating “It is difficult to capture data on individualized post-acute care plan compliance. Ensuring continuity of care, regardless of where patients seek care after their stroke, is our biggest challenge. We struggle to be able to demonstrate quality transition of care metrics when certification bodies evaluate our programs.”
Supporting both patients and hospitals in the post-acute stroke space means making stroke navigation a standard of practice.
Navigation Services as a Standard of Practice
Effective Principal Illness Navigation (PIN) for stroke patients must address barriers to accessing care as a result of socioeconomic factors. This is both a common patient need, and a requirement of hospital accreditation guidelines. Where typical stroke navigation programs focus primarily on clinical follow up to ensure that appointments have been made, prescriptions are filled, and initial stroke risk factors are addressed– PIN emphasizes care coordination, resource provision, and adaptation to post-stroke sequelae to address holistic and intersecting recovery needs. This person-centered assessment and support leads to overall improvements in illness-specific health outcomes.
“The current AHA guidelines are often developed through analysis of data submitted by hospitals to the Get with the Guidelines registry, and are, as a result, focused on the acute phase of stroke. We need to consider how to integrate post-acute metrics into our current evidence-based guidelines,” stated Seagraves. “As the navigation program metrics continue to support that PIN can improve health outcomes in post-acute stroke care, we can advocate for this evidence-based model to become a standard of practice.”
In addition to working alongside accreditation agencies to support the development of navigation services in post-acute stroke care, Alexandrov recommends building awareness in the acute care provider communities. “It’s about showing stroke clinicians in acute care what a navigator does.” She elaborated, “We need to partner with clinicians and medical schools nationwide to help them understand the patient experience and PIN program capabilities.”
Kandu continues to showcase its program evidence in venues with industry leaders, accreditation agencies, payors, and hospital systems to push for a new standard and the future of post-acute stroke care. Kandu offers healthcare providers a streamlined way to integrate the PIN model of post-acute care with robust, scalable, evidence-based programming. There is an opportunity for stroke clinicians to support this shift in post-acute stroke care by taking the lead in bringing Principal Illness Navigation services to their hospital systems to enhance patient outcomes and shape the future of post-acute stroke recovery.
Anne Alexandrov, PhD, RN, CCRN is a professor of Nursing and Neurology at the University of Tennessee Health Science Center (UTHSC). She developed and leads advanced practice provider fellowship in acute stroke called NET SMART AP and is considered the leading international nursing expert on acute stroke management.
Karen B. Seagraves, PhD, MPH, NEA-BC is a Clinical Nurse Specialist and Nurse Practitioner, who has a masters in public health and extensive experience in healthcare leadership and consulting. She is a former enterprise vice president of neurosciences and executive director of a comprehensive stroke center.
Tailar Johnson, OTD, OTR/L is a Clinical Researcher with Kandu Health based in Campbell, California.
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Feasibility of a Telemedicine-Based Principal Illness Navigation Service Following Hospital Discharge After Acute Stroke
Peer-reviewed paper published in Stroke Clinician, the official Journal of the Association of Neurovascular Clinicians
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