Study Led by DNP Students Finds That Home Care Improves Stroke Outcomes

Two Doctor of Nursing (DNP) students at the University of Rochester School of Nursing led a pilot study that found that stroke patients who are paired with caregivers who help them transition back to their homes are significantly less likely to be readmitted to the hospital. The results of the study, which showed a 39 percent reduction in the readmission rates of stroke patients at Strong Memorial Hospital, were presented at the International Stroke Conference in Texas. 

The study was authored by DNP students Ann Leonhardt Caprio, MS (’06), RN, ANP, with the UR Medicine Comprehensive Stroke Center and Denise Burgen, MS (’94), MBA, MSN, FNP, RN, with UR Medicine Home Care, as well as their colleague Curtis Benesch, MD, MPH, also with the Stroke Center. 

“This initiative exemplifies the contributions our school’s graduates can have on health care delivery and in the lives of patients, and it shows what can be accomplished when professionals from different disciplines come together to work toward a common goal,” said Lydia Rotondo, DNP, RN, CNS, associate dean for education and student affairs and the director of the DNP program at the UR School of Nursing.

The study focused on one of the measures used by the Centers for Medicare and Medicaid Services to determine quality of stroke care – whether or not a patient is readmitted to the hospital within 30 days of being discharged after suffering a stroke.

The staff at Strong Memorial Hospital worked with UR Medicine Home Care to develop a care program that ensured that patients who had suffered an ischemic stroke had additional support and resources once they left the hospital and returned to their homes and communities. The researchers used the Coleman Care Transition Model, which has been successfully employed with other patient populations but had not been evaluated to reduce stroke readmissions.

The program starts when the patient is still in the hospital and is introduced to a “coach” with UR Medicine Home Care. The coach participates in the discharge planning and works with the patient to help them distinguish between symptoms that may be normal during recovery and those that require medical attention, helps them understand their medications and when and where their follow-up appointments will occur, and ensures that the patient has the necessary support waiting for them at home. Once discharged, the coach follows up with a home visit within 24-48 hours and weekly phone calls.

Strong Memorial Hospital’s 30-day readmission rate for stroke patients dropped from 7.8 percent to 4.7 percent after the home care program was implemented, a 39 percent reduction.