Stroke is the fifth leading cause of death in the U.S. and a leading cause of long-term disability. About 15,000 military veterans are hospitalized for acute ischemic stroke each year, and $274 million was spent for their acute, postacute, and subsequent stroke-related care over the first 6 months following the stroke.1
The Durham VAMC (DVAMC) lies within the country’s “stroke belt,” an area of 8 contiguous southeastern states, and provides care to more than 200,000 veterans living in a 26-county area of central and eastern North Carolina. The stroke mortality rates in this region are up to 40% higher than that of the national average rate.2 The DVAMC sought to transform the organization of stroke care provided to hospitalized patients as an important step in optimizing their outcomes.
Background
The VHA is committed to providing high-quality, evidence-based health care and collects data reflecting its services, including care processes and outcomes. The 2009 Office of Quality and Performance report raised concerns about the delivery of stroke care within the VHA, based on an assessment of several quality indicators. This led to the 2011 VHA directive providing policies based on national standards for the management of acute ischemic stroke (AIS) in VHA medical facilities.3
The directive defined 3 types of VHA facilities: primary stroke centers, limited-hours stroke facilities, and supporting stroke facilities. The directive further required that “all VA medical facilities with inpatient acute care medical or surgical beds have a written policy guiding appropriate care to patients with AIS in place by January 1, 2012, and implemented no later than June 1, 2012,” which included “protocols or pathways for the rapid identification, evaluation, and treatment” of patients with acute stroke and monitoring of appropriate performance indicators. For many VHA facilities caring for patients with acute stroke, including the DVAMC, the directive necessitated the development of multidisciplinary teams, organized around the provision of stroke care.
DVAMC Stroke Program
A disease-specific program typically involves the coordination of multiple care components and aims to improve continuity of care. The approach is intended to reduce care fragmentation. Through an already existing program, many elements of stroke-specific care were being delivered at the DVAMC, but several gaps and no formal system existed for coordinating stroke-related care. Programmatic goals were developed to optimize adherence to national stroke-related process measures; minimize morbidity mortality, duration of hospitalization, postdischarge emergency department (ED) visits, and readmissions; and improve continuity of care.
The Team
The DVAMC is affiliated with Duke University School of Medicine and Duke University Medical Center. The Duke University Medical Center is a Joint Commission-certified Comprehensive Stroke Center, and its director also serves as the director of the Durham VAMC Stroke Program. Because of the time and clinical expertise required to develop and oversee the program, a critical initial step was to identify a dedicated stroke program coordinator (SPC) to integrate care services and manage its implementation and ongoing activities.
The specific responsibilities of the SPC vary, depending on a facility’s needs, goals, and resources. The SPC may serve primarily as the quality measure expert and data manager, have responsibilities for program implementation and maintenance, provide training for hospital staff, and help optimize communication and integration of neurologists, internal medicine teams, other consulting and treating services, and nursing and allied health providers. The SPC also may provide direct patient care, act as a case manager, and monitor longer-term outcomes.
The DVAMC SPC is a nurse practitioner (NP). The training was thought essential given an NP’s ability to work autonomously, manage all elements of care, conceptualize, collaborate, and provide medical management skills, as has been found beneficial in many other systems of care redesign.4 The DVAMC is a teaching hospital with much of the staff affiliated with Duke University Medical School and supervised by a team of expert attending physicians. The SPC’s roles at the DVAMC have been to facilitate program development, implementation, and maintenance and collect performance data and achieve quality metric goals.
Obtaining support and cooperation from all members of the health care team is necessary for success. Finding “champions”—selected staff with an interest in improving stroke care—is crucial to a multidisciplinary team approach. These staff members were identified and recruited to serve on work groups and task forces. The SPC served as the leader and as a resource for these teams.
Key Functions
The American Stroke Association’s Policy Recommendations for the Establishment of Stroke Systems of Care suggest that a stroke system should serve 3 critical functions: communication and collaboration, standardize care customized to the population, and include performance measures with a mechanism for evaluation.5