Risk Factors in 90-Day Ischemic Stroke Readmissions
Summary of Data Presented by: Lauren Sheehan, OTD, OTR/L and Kiffon Keigher, DNP, MSN, ACNP-BC, BSN, BSPA, SCRN, FAHA
25.9% of Medicare Fee for Service members discharged alive from an inpatient ischemic stroke admission are readmitted to a hospital within 90 days¹. Multiple comorbidities and demographic features significantly increase the odds of readmission– including race, differences in index hospital stay characteristic, and eligibility for Medicaid.
Most readmissions are due to causes other than recurrent stroke, as stroke survivors are uniquely vulnerable to impairment-related causes of readmissions including falls and infections due to their new impairments. Examining longitudinal Medicare Fee for Service claims data for patients discharged after ischemic and hemorrhagic stroke reveals that the leading cause for readmission transitions from recurrent stroke and TIA, to sepsis and infections within 30 days post-discharge¹..svg)
This analytic data set is constructed using the Centers for Medicare and Medicaid Services Standard Analytic File Longitudinal Data Set 100% inpatient and outpatient claims for Medicare Fee for Service (FFS) patients who experienced ischemic stroke in CY 2018.
Limitations and Barriers to Stroke Recovery
Stroke survivors have limited tools and resources upon discharge from the hospital after a stroke and subsequently face significant challenges in navigating their discharge plan and overall recovery. Cognitive issues, communication problems, psychosocial symptoms, and adjustment to functional changes all pose barriers to patient recovery if not adequately addressed. Stroke survivors often do not get the care appropriate for their health conditions when they experience difficulty navigating the complexities of the healthcare system or if they have Social Determinants of Health (SDOH) limiting their access to care.
Clinicians also encounter common challenges that make it difficult to provide optimal care at discharge for stroke patients' complex needs. Some of the challenges clinicians face include:
- Lack of alignment among multiple providers regarding the patient's care plan
- Difficulty coordinating discharge transitions due to resource and time constraints
- Gaps in the education provided to patients and their families
- Discharging patients with unmet psychosocial and SDOH needs
- Difficulty getting patients scheduled for and returning to follow-up appointments
Demographic Differences
Index Hospital Stay Differences
Comorbidity Differences
This data was first presented at the 2024 American Association of Neuroscience Nursing (AANN) Advances in Stroke Care Conference and is on file at Kandu Health.
Improving Transitional Care Workflows
The presence of multiple comorbidities and demographic features, including race, differences in index hospital stay characteristics, eligibility for Medicaid, and other comorbidities, significantly increase the odds of readmission. Efforts to reduce readmissions should be informed by both these comorbidities and the SDOH needs of each individual patient. Based on patient demographics and comorbidities that correlate with higher readmission rates, transitional care workflows may be able to mitigate the risk for readmissions by improving certain aspects of the patient transition from inpatient to home.
- Encourage staff to participate in conferences or mentorships teaching best practices
- Evaluate and intervene on identified health inequities
- Including rehab and home visits in follow up care services for the disabled population
- Provide follow-up education and ensure that early recovery needs are met
- Ensure that patients with a longer length of stay have more opportunities for education
- Consider a stroke navigator to assist the stroke patient through a personalized recovery plan
- Modeling the patient transitional journey to include a post-acute care stroke clinic
Innovating Post-Acute Care
In 2024, the Centers for Medicare & Medicaid Services (CMS) introduced coding and coverage for Principal Illness Navigation (PIN) services. The CMS coverage of PIN services was developed based on decades of work in cancer navigation². This model of care, when applied to stroke care, has shown that navigation services can help reduce health disparities and improve patient outcomes². It has also established standards for the ethics, qualifications, knowledge, skills, activities, and supervision of navigators²..svg)
PIN is applicable to post-acute stroke care and covers a range of services to optimize patient recovery by facilitating access to education, recovery resources, community, and other clinical resources. This holistic model of care provides stroke survivors with the opportunity to maximize their recovery. While PIN must be administered in an outpatient setting, Kandu Health offers a simple solution for healthcare providers to begin offering PIN as an extension of the care stroke patients receive at the hospital. Together, we can provide improved continuity of patient care to achieve better quality of life for stroke survivors and their care partners.
The research presented by Lauren Sheehan and Kiffon Keigher was conducted in collaboration with Kandu Health using data from the Centers for Medicare and Medicaid Services on patients who experienced a stroke in 2018. Additional support by Mary Jo Braid-Forbes, MPH, Braid-Forbes Health Research.
Contributors:
Lauren Sheehan, OTD, OTR/L is the Senior Director of Clinical Services at Kandu Health, based in Campbell, CA
Kiffon Keigher, DNP, MSN, ACNP-BC, BSN, BSPA, SCRN, FAHA is the Program Manager of the Cerebrovascular and Stroke System at Advocate Health Care
Kandu Health delivers remote navigator-led support to stroke survivors and care partners after hospital discharge. We provide education, counsel, and resource navigation, community support groups, through a clinical Navigator and easy to use app.
