Post-Acute Stroke Care

How to demonstrate value of a home-based, post-acute stroke care team?

We have developed a post-acute, home-based stroke care model (“Stroke Mobile”).  Each care team consists of an RN and lay educator and patients are managed up to 1 year post-dischage.  Metrics include 30-day all cause readmission and mortality, 90-day functional outcome, rates of risk factor control, medication adherence etc.  The model was initially supported by a CMS Innovation grant and data indicate significant clinical benefit (e.g., low readmission rates, BP control approaching 90% at 1 year, etc).  Now that the grant support has ended, we are struggling to demonstrate financial value of the model despite the clear clinical benefits.  Any ideas would be most appreciated.


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Specialty Referral Management/Care Coordination

Participant comments on Post-Acute Stroke Care

  1. Could you share some of your data? Things such as –

    1. Readmission rates reduced from what to what?
    2. Mortality rates decreased from what to what?
    3. How often were the home visits?
    4. How long to BP control, on average? 90 days? 180 days?
    5. Could this have been accomplished in less time?
    6. Could this be accomplished with a blend of home and office visits?
    7. Home PT/OT? How often?

    These CMS grants can be difficult…find costly successes, but then funding dries up. I think if you look at the data carefully, you may find the things that were the highest “bang for the buck”, eliminate things with a lower ROI, and get the project close to cost neutral.

  2. Thank you for your input. We are still working on some of the analytics and don’t have adequate ideal “controls” for many metrics as we didn’t prospectively randomize patients to Stroke Mobile or traditional care; this is the basis of a recent grant submission. We are using a blend of historical rates (when available), industry rates and are partnering with our major payor to compare our outcomes to patients treated at other facilities in our state.

    The grant protocol was an in-home visit monthly for 12 months but we have modified that in the post-grant period to a blend of in-home and telephone visits. Our post-grant 30-day readmission rate is 6% and our BP control rate (average of any visit is 88%). To your point, data during the grant period indicate the major BP value occured by 90 days. I suspect reducing the intervention from 12 to 3 months is where we are headed.

  3. I think the willingness to fund it would definitely go up if the outcome of the cohort is demonstrating the value of the program. Beyond mortality and readmission, is your team collecting quality of life, ADL, Functional mobility outcome? Are you looking at reducing the risk for institutionalization, falls at home etc. as well.

    1. We are collecting Stroke Impact Scale (SIS) which is a functional scale, Morisky medication adherence etc. Have not collected falls.

  4. In Cork University Hospital we have developed (as part of a national stroke programme) a comprehensive Stroke service over the past 4 years. We have encountered difficulties in the post acute management of that cohort of patient who require placement elsewhere with support in the community. We are now implementing a community support service with therapies commencing later this year – again supported by the national programme who have recognised the importance of the patient pathway seamlessly extending from the hospital to the community.

    I think the financial value of such an initiative needs to be looked at in the context of the “opportunity cost” of not investing in community services which effectively means slower throughput of patients, longer lengths of stay and the capacity to treat other patients foregone which may in itself represent financial income foregone.

  5. Thank you for your input.

  6. Hello GTTJ,
    To make it financially sustainable or demonstrating the financial value of the home-based team, I would compare the medium cost of a patient treated at the hospital vs. the patient treated at home.
    Using the Time Value Based model learned in module II, what are the total costs of the treatment at the hospital (remember, using all related costs)? What are the total costs of the home-based treatment? How many more patients could you treat if the money used for treating them in the hospital was used invested in a home-based team?
    In other words, if you are looking for a financial value, I would make a business case.

  7. Thank you. We can certainly quantify the savings by freeing up MDs to see New Patients while the RNs are seeing patients at home.

  8. Its a great program and taking care morbidity is bigger challenge. It can easily become a scalable business model wherein you can expand in other places as well. We need to involve all the stakeholders in the process. Lets show the value to Govt. Some funding can be raised from PE firms based on IRR and scalability. Some coverage in insurance is another option.

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