A connected care management program for stroke and other inpatient rehabilitation patients could work for all at-risk patients as they transition from inpatient acute care to rehabilitation care, home health, and the community.

“The care transitions program is designed for any patient leaving the inpatient setting and transitioning home to home health and hospice,” says Kristi Wimberly, PT, director of care transitions at Encompass Health, Home Health & Hospice in Dallas. “We have certain things we do for more complex transitions. Our gold standard is bedside transitional care assessment.”

Many patients who have suffered a stroke and need rehabilitation to learn to walk, talk, swallow, and take care of their activities of daily living (ADLs) will stay in inpatient rehabilitation hospitals.

Inpatient rehab provides a high level of medical oversight with three hours of therapy, five days a week, and meeting with a rehabilitation physician at least three times a week, says Elissa Charbonneau, DO, MS, chief medical officer at Encompass Health in Birmingham, AL.

“In 2016, the American Heart Association and the American Stroke Association published revised guidelines that said people who had a stroke are best served in inpatient rehabilitation hospitals rather than skilled nursing facilities,” Charbonneau says. “The guidance added to our commitment for patients who have had a stroke.”

Once patients have received comprehensive inpatient rehab services, they usually will need some follow-up care in the community. Encompass Health works with home health and hospice providers, including the company’s own, to help provide warm hand-offs and smooth care transitions to the community. “We’re in a unique position to collaborate and work together to make sure patients are followed throughout the care continuum,” Charbonneau says.

“It’s very exciting for case managers because they’re very important, and this is an area where doing good case management to keep patients out of the hospital is extremely rewarding,” she adds. “They can’t do it alone; it takes a team, and everyone needs to be committed to it.”

The first step is to evaluate patients to ensure they are placed in the right setting for post-acute care, Charbonneau says.

“We have clinical transition coordinators who follow patients once they come into the inpatient rehab hospital, and they are the primary communication persons once patients are discharged to the home health side,” she explains. “This is helpful because the coordinators are integrated into the weekly team conferences we hold for all patients.”

The inpatient rehab team conferences discuss patients’ progress in reaching discharge goals. Attending these meetings helps transition coordinators learn what is needed to ensure a safe and seamless discharge.

“They can arrange to have a nurse come out on the day of discharge to assess patients and make sure they are OK and understand the medicine,” Charbonneau says. “It’s a continuum of care, rather than the patient leaves one place and there’s no [provider] communication, which is when people fall through the cracks.”

At the first meeting with patients, the care transition coordinator will say “I’m a nurse, a care transition coordinator, and I’m here to assist with your transition to care,” Wimberly says.

“Everything we find goes into our medical record so operational and clinical partners can see what we’ve learned during that transitional visit,” she explains. “They can anticipate barriers and be prepared for high-risk patients.”

In addition to care coordination notes, there is a clinical snapshot attached to patients’ medical records. Clinicians must review it before seeing the medical records, Wimberly notes.

“It has information about caregivers and diet. If the patient is a stroke patient, there are swallowing precautions, a note on whether a swallow study was completed, communication about language barriers, transfer techniques, precautions they might be under, and anticoagulation medication following a stroke,” she explains.

The goal is to complete a care visit within 24 hours of discharge and to provide follow-up for 48 hours, ensuring everything has gone smoothly with the transition, Wimberly says.

“If the start of care is delayed, or if there is a very high-risk transition with potential barriers, we may be involved a little bit longer,” she adds.

The home health program includes care transition coordinators — nurses and therapists housed in the inpatient facility. Care transition coordinators collaborate with all providers to gain the most accurate picture of patients’ progression toward goals and to assess patients prior to discharge, Wimberly says.

“All transitions happen at the discharging facility, which collaborates with the care team to get the most accurate picture and an assessment of patients prior to discharge,” she says. “We review the medical record clearly, speaking to the care team and working with a multidisciplinary team of pharmacists, respiratory therapy, a wound nurse, depending on what that patient needs.”

Risk stratification helps the team identify high-risk patients and potential barriers, including psychosocial and environmental factors, Wimberly says. (See story on risk stratification in this issue.)

“If we identify potential barriers, we work with case managers and social workers prior to discharge,” Wimberly says. “We make recommendations on our end when we identify risk factors, and we have a social worker added to the care plan.” If patients need transportation or Meals on Wheels, the case management team makes it happen.

Care transition coordinators work with patients and their families to review the medical record and start preliminary medication reconciliation, looking for errors and changes made to patients’ home medication regimen, she adds.

“We make sure patients understand the medications they are taking and any changes made to their prescriptions,” Wimberly says. “When we find medication errors, like something that wasn’t discontinued but should have been prescribed for only the hospital stay, we address those prior to discharge.”

Care transition coordinators also help patients address care barriers, such as transportation to the pharmacy, financial burdens, cognition problems, and visual impairments.

“All of these things play into a patient’s ability to adhere to the medication regimen,” Wimberly says. “We also collaborate with the patient and specialist to make sure all follow-up appointments are scheduled.”

Coordinators send discharge summaries to community providers prior to the first visit. They work to connect patients to their doctor within three to five days after discharge. Prior to the care transition program, patients might not have seen their provider for four to six weeks, due to scheduling obstacles, she adds.

“We let doctors know the patient was hospitalized and has a high risk for readmission, and we are able to get the patient scheduled for a visit a little quicker,” Wimberly says.

Coordinators can use checklists to help with handoffs. For instance, when patients are discharged with heart failure or a deep wound, case managers will need to go a little deeper into the transition to ensure they do not experience recurring medical emergencies. “We can do a complex checklist,” Wimberly says. “Sometimes, it requires a live handoff, where we pick up the phone and give reports.”

Case managers ensure the patient’s plan of care will continue during the transition and that community providers receive all discharge summaries, medication lists, and medical records, she adds. “We work with community physicians to make sure we have everything in place to deliver care in the home setting,” she says.

Encompass Health’s focus on care management is designed to produce the best outcomes for stroke patients and other patients, Charbonneau says. “This model helps patients reach their maximum potential,” Charbonneau says. “We make sure they have appointments, transportation, and all of those case management-related things that help them carry over to the next place.”