Building A Bridge: Study Led by DNP Student Links Transition of Care to Reduced Hospital Readmissions

The transition of care from hospital to home can make all of the difference in a patient’s recovery from a stroke.

Ann Leonhardt-Caprio, DNP, RN, ANP-BC, FAHA, a recent University of Rochester School of Nursing Doctor of Nursing Practice (DNP) graduate, led an initiative to improve the systems of stroke care for patients discharged from the hospital after an ischemic stroke (IS).

The complicated transition of care from hospital to home can contribute to hospital readmissions, which are correlated with a higher risk of death and disability as well as increased health care costs to patients and the health care system. There may also be an increased risk of recurrent stroke in patients whose transition from hospital to home does not go smoothly.

Thirty-day hospital readmission rates count towards quality ratings from the Centers for Medicare and Medicaid Services (CMS) and may be part of reimbursement contracts with other insurers which impact hospital reimbursement. High readmission rates can lead to financial penalties or decreased reimbursement to hospitals.

Available research surrounding 30-day readmission of stroke patients demonstrates that multi-component interventions are more successful in reducing readmissions. According to Leonhardt-Caprio, a “quick fix” is not the right answer. “The transition of care is not a one-size-fits-all approach. Every patient is a little different, and every patient’s reason for coming back to the hospital is not the same,” she said.

“Some patients don’t comprehend or didn’t get enough education before they left the hospital to understand what they need to know to prevent infections or how to manage their medications. They could have difficulty swallowing, which can lead to pneumonia. They may be on a new blood thinning medication and need follow-up education on how to take it and what side effects to be cautious of. A lot of problems could be prevented if there is more support at home before anything serious happens that requires readmission to the hospital.”

As the program coordinator at the UR Medicine Comprehensive Stroke Center (CSC), Leonhardt-Caprio ensures the center engages in evidence-based practice of stroke care and quality improvement processes across the institution. The CSC is a participating hospital in the Paul Coverdell National Acute Stroke Program, which is a Centers for Disease Control (CDC) sponsored program that emphasizes quality improvement focusing on stroke systems of care.

When Leonhardt-Caprio learned of New York State’s participation in a transitions of care pilot program which emphasized the formation of partnerships, she recognized this aligned with what she wanted to do as part of her DNP project.

A three-month audit of the transition of care process from hospital to home identified that less than half of stroke patients were being referred to a certified home health agency (CHHA). Leonhardt-Caprio reached out to Jane Shukitis, president and CEO of UR Medicine Home Care, and initiated a partnership that would play a key role in both the New York State Coverdell pilot program and her DNP project. Leonhardt-Caprio entered the DNP program to improve her skills as a stroke program coordinator and an advanced practice nurse.

“The DNP has given me the ability to reframe how I view systems and to recognize that I can grow programs, initiatives, and improve processes to benefit not only individual patients, but health care systems as a whole, which is what helped make this initiative successful.”  

Starting in July 2019, Leonhardt-Caprio implemented a multi-component improvement intervention to bridge the transition from hospital to home through increased CHHA referrals, post-discharge telephone calls, and enhanced communication with outpatient providers through more timely discharge summaries.

In the reimagined home care referral process, UR Medicine Home Care coordinators were involved earlier in a stroke patient’s hospital course, which allowed eligibility and needs assessment to be placed in the hands of the home care expert. Leonhardt-Caprio went on home visits with a CHHA nurse to experience for herself the benefits of home care services and “was truly impressed by how important it is to see a patient in their home environment. Nurses in the home can check what medications the patient was discharged on and compare that to what they have in their home. Nurses and therapists would also evaluate risk factors in the patients’ homes like throw rugs they could easily trip on, which is critically important in patients who have new deficits from a stroke.” Leonhardt-Caprio worked to educate the inpatient team on these benefits to help with increasing CHHA referrals.

Instead of the prior practice of one-week, unscripted telephone follow-ups, nurses would call two to three days after discharge using a script that assessed transition of care needs and provided the nurses with some guidance for different scenarios that may be problematic: transportation, prescriptions, outpatient appointments, understanding of discharge instructions, etc. Providers were asked to complete discharge summaries within two days of hospital discharge to ensure the communication with outpatient providers was timely.

For months, Leonhardt-Caprio and others, including UR School of Nursing’s Craig Sellers, PhD, RN, AGPCNP-BC, GNP-BC, FAANP, Elizabeth Palermo, DNP, RN, ANP-BC, ACNP-BC, Thomas Caprio, M.D., Chief Medical Officer for UR Medicine Home Care, and University of Rochester School of Medicine and Dentistry’s Robert Holloway, M.D., M.P.H, measured readmission rates of IS patients who were discharged from one of UR Medicine’s stroke units at Strong Memorial Hospital.

After six months, they saw a 54% decrease in hospital readmissions for all IS patients and a 62% decrease in readmissions for those patients who were discharged to home, which was the group the initiative specifically focused on.

As a result of the impressive results and the partnership with UR Medicine Home Care, Leonhardt-Caprio’s project was nominated by the New York State Coverdell team as an exemplar of a partnership to improve stroke systems of care. The partnership was selected by the CDC as one of three programs in the country to participate in a case study evaluation to gather information regarding efforts within a stroke system partnership. The CDC conducted a virtual site visit in late March to interview participants who were involved in the implementation and execution of the project. The CDC will use the findings to provide an in-depth understanding of how partnerships improve the quality of stroke care and ultimately contribute to the public evidence of effective stroke systems of care.

While the study demonstrates the importance of improving transitions of care to reduce avoidable readmissions, Leonhardt-Caprio emphasizes that readmission rates for stroke patients should never be zero.

“After a stroke, we expect that about three percent of patients are going to have a recurrent stroke within the first 30 days, and no matter how good the overall education and prevention strategies are, some patients will still have a recurrence. We’re never going to prevent all of the strokes or serious medical conditions that require hospitalization. So, it’s really important for us to focus on improving that transition of care to reduce the preventable readmissions, but not discourage patients from getting acute care when they need it,” she said.

In March, Leonhardt-Caprio presented the project results—one of six oral abstracts presented as a part of the State of the Science Nursing Symposium— at the International Stroke Conference. Leonhardt-Caprio also spoke about the project at the NorthEast Cerebrovascular Consortium 14th Annual Summit, and to the CDC’s Coverdell Post-Hospital Work Group in late 2019.