Comparison of the Effects of Two Models of RN Led Post-Discharge Care for Stroke Patients
Advisor:Gottesman, Mary Margaret
Post Discharge Care
Readmission rate reduction
RN Home Visit
Follow up phone call
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Publisher:The Ohio State University
Series/Report no.:The Ohio State University. College of Nursing Doctor of Nursing Practice Final Document Projects
Stroke causes a significant health burden for the patient who experiences a stroke and for their family and caregivers. Individuals who experience a stroke are often left to cope with severe disabilities that can impact the quality of life of the individual and their family. The Centers for Medicare and Medicaid Services, as well as many national quality organizations, has identified improving transitions in care as a priority. Improving the transition of stroke patients from hospital to home can have a positive impact on patient outcomes and long term function. Purpose: The purpose of this project was to conduct an exploratory proof-of-concept feasibility study comparing two models of RN led post-discharge care for stroke patients. The models were evaluated based upon effectiveness and cost. Effectiveness was measured by the patient’s satisfaction with transition using the Care Transition Measures-3 (CTM-3), use of the emergency department, readmission for any reason, and the number of identified medication discrepancies and home safety issues. Cost was evaluated by a comparison of the actual staff costs between the two interventions. Readmission rates and changes in satisfaction were compared with historical data for the facility. Question: In acute stroke patients post discharge, which is most effective: a follow up phone call by an RN or a home visit by an RN in reducing all cause hospital readmissions and emergency department use, and enhancing the patient’s satisfaction with the quality of the care transition at 30 days after discharge? Site: The facility where the project took place is certified as a Primary Stroke Center by the Joint Commission, caring for approximately 120 acute stroke patients yearly. Patients discharged from an acute care unit or the inpatient rehabilitation unit to a non institutional setting and who had a Functional Independence Measure (FIM ™) cognitive score indicating the need for minimal assistance, were asked to participate in the study. Findings: The number and types of issues with medication reconciliation and safety in the home were recorded during the RN phone call or RN home visit within four days of discharge. Readmission, use of the emergency department and patient satisfaction were assessed 30 – 35 days after discharge. The results of the project demonstrated the feasibility of pursing a future randomized controlled trial to address the effectiveness of each of the two models of RN-led post-discharge care as compared to usual care, which does not have an RN-led post discharge intervention.
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