J Nurs Care Qual

Vol. 29, No. 3, pp. 237–244

Copyright Ⓧc 2014 Wolters Kluwer Health | Lippincott Williams &
Wilkins

Outcomes of a Quality
Improvement Project
Implementing Stroke Discharge
Advocacy to Reduce 30-Day
Readmission Rates
Kristen M. Poston, DNP, NP-C; Bonnie
P. Dumas, PhD, MBA;
Barbara J. Edlund, PhD, APRN, ANP-BC
The purpose of this quality improvement project was to determine whether use of aspects
of a transitional care model by nurse navigators would affect 30-day readmission rates in
hospitalized ischemic stroke patients discharged home with self-care. Thirty-day
readmission rates and emer- gency department (ED) visits were compared before, during,
and after the implementation of the revised discharge process. Comparative analysis
demonstrated reductions in readmissions and in ED visits. Thirty-day readmission rates to
our hospital decreased from 9.39% to 3.24% when com- paring pre- with postintervention
data. Thirty-day ED visit rates to all state hospitals decreased from 16.36% to 12.08% when
comparing pre- with postintervention data. Key words: continuity of pa- tient care,
discharge planning, evidence-based nursing, patient discharge, patient
navigators, quality improvement, readmission rates, stroke, transition care

NDER THE PATIENT Protection and Af- DOI: 10.1097/NCQ.0000000000000040

U fordable Care Act Hospital Readmissions

Reduction Program, acute care settings will
be held responsible for managing care
transi- tions and will be subject to financial
penalties for readmission rates higher than
established national averages.1 Ensuring
quality transi-

Author Affiliations: CVS Minute Clinic (Dr

Poston); and Medical University of South
Carolina College of Nursing (Drs Dumas and
Edlund), Charleston, South Carolina.
The authors acknowledge Tina Daigle, BSN,
RN, CNRN, and Perette Sabatino, MSN, RN.
The authors declare no conflict of
interest.
Correspondence: Kristen M. Poston, DNP, NP-C,
CVS Minute Clinic, 397 Culver Ave, Charleston,
SC 29407 (kristenposton@yahoo.com).
Accepted for publication: November 3, 2013.
Published ahead of print: December 6, 2013

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is
prohibited.
 tions through comprehensive and
consistent discharge plans along with
postdischarge sup- port can reduce
readmissions and improve health
outcomes.2 Examining deficiencies in care
transitions is particularly relevant, as more
than 32 million adults are discharged from
US hospitals each year.3
Rehospitalizations among Medicare
benefi- ciaries are frequent, costly, and are
often as- sociated with gaps in follow-up
care.4,5 Al- most one-fifth of Medicare
beneficiaries are rehospitalized within 30
days and one-third within 90 days
translating to a cost of $17 billion dollars,
almost 20% of Medicare’s hos- pital
payments.4,6 It is estimated that 3 quar- ters
of these readmissions are potentially
preventable.6 The Patient Protection and
Af- fordable Care Act attempts to address
this by examining readmissions at
hospitals that are paid for diagnosis-related
group payments by authorizing lower
payments to hospitals with high-risk
standardized rates of readmission.7,8

237

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is
prohibited.
238 JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2014

The Centers for Medicare & Medicaid The 2 components that were successfully
Services (CMS) currently calculates an completed for most of the intervention group
average risk- adjusted, 30-day hospital patients in Project RED were (1) discharg- ing
readmission rate.8 The CMS will penalize a patients with a primary care appointment
hospital the following year for all Medicare
admissions proportional to its rate of
excess rehospitalizations for tar- geted
conditions if the risk-adjusted rate ex-
ceeds the calculated average.8
The CMS policies have prompted many
hos- pitals to examine their transition of
care pro- cedures through exploring the use
of transi- tional care models, models that
demonstrate successful interventions to
move patients from one care setting to
another.9 The Insti- tute for Healthcare
Improvement supports the transitional care
model Project Re-Engineered Discharge
(RED) as the strongest evidence for
improved hospital discharge processes. 10
RED was initially developed as a
randomized controlled trial of 749 patients
admitted to the medical teaching service of
Boston Med- ical Center.3 It was designed
to test the ef- fects of an intervention to
minimize hospital utilization after
discharge.3 RED has since de- veloped into
an operationalized toolkit and training
model comprising the mutually re-
inforcing components tested in the study. 11
RED toolkit offers a standardized approach
to discharge planning with a goal to help
health professionals and hospitals adopt the
RED program and deliver safe and
effective discharges.11
RED uses nurse discharge advocates to
carry out 9 in-hospital components of an
11-component bundle.3 The 9 in-hospital
components include interventions such as
ar- ranging posthospital follow-up with
primary care providers (PCPs), providing
discharge in- formation to PCPs, educating
patients about diagnoses throughout the
hospital stay, and confirming the
medication plan.3,10,11 RED re- duced
rehospitalizations and improved post-
discharge quality of care, goals that CMS,
the National Quality Forum, and the
Institute of Medicine have identified as a
priority for demonstration projects and
research.9
(94% of patients) and (2) sending that outpatient follow-up and evaluation by
discharge summaries to PCPs within 24 a health care provider outside of a specialty
hours (91% of patients).3 In addition, could decrease readmissions.13
several aspects of follow-up Several other care transition models
appointments were discussed with have demonstrated the effectiveness of
patients before discharge including standardized discharge processes, further
under- standing the importance of supporting the use of a consistent frame-
physician follow- up, identifying a work, including the BOOST model and the
transportation plan, and con- firming
appointment location.3 RED was able
to decrease cost by 33.9% in their
intervention group, as well as decrease
hospital utilization by 30% within 30
days after discharge.3 In addition,
intervention group participants re-
ported seeing their PCP more,
optimizing the opportunity for PCPs to
detect and take care of outstanding
issues.3
The efficacy of establishing
postdischarge follow-up with a PCP
and faxing a discharge summary for
PCP availability has been demon-
strated in other studies as well.12,13 One
study, in particular, focused on
discharge summaries that were
available to the physician prior to a
follow-up visit after hospital
discharge.12 Pa- tients who were seen in
follow-up by a physi- cian who had
received a discharge summary before
the visit were less likely to be readmit-
ted to the hospital.12 This study
suggested that only a small number of
discharge summaries were available to
physicians at follow-up be- cause
hospital physicians failed to identify
all providers involved in a patient’s
care and failed to ensure that
summaries were sent.12
A study of the heart failure
population demonstrated the
importance of early physi- cian follow-
up after discharge. 13 Hospitals that had
higher early follow-up rates had a
lower risk of 30-day readmissions. 13 In
addi- tion, all causes of 30-day
readmissions were lowered when
patients were discharged from a
hospital that had a greater proportion of
pa- tients receiving early follow-up. 13
This outpa- tient follow-up occurred
mostly with general internists rather
than cardiologists, which sug- gests
 Stroke Discharge Advocacy to Reduce Readmission
Rates 239
hospital’s stroke population. In our
Care Transitions Intervention model. 14,15 academic medical center, the neurol- ogy
Studies examining these models have team was not using a transition of care
shown decreased rehospitalizations, as model as a guide to discharging its
RED did, using well-executed hospital ischemic stroke patient’s home with self-
discharges that improve flow of care. Although
information and downstream
communication between inpatient and
outpatient settings.14,15 None of these stud-
ies, however, have focused specifically on
distinct populations; rather, they
established generalizability in medical
settings.14,15 The success of the RED
initiative was the motiva- tion for
implementing a quality improvement (QI)
project in our hospital using key aspects of
a transitional care model.

LOCAL PROBLEM

The Patient Protection and Affordable

Care Act Hospital Readmissions Reduction
Pro- gram recognizes readmission as an
admission back to the same hospital or to
another hos- pital within 30 days of
discharge.16 Although excess readmission
ratios and subsequent pay- ments will only
initially affect the diagnoses of myocardial
infarction, heart failure, and pneu- monia,
additional diagnoses such as stroke may be
added in the future, as CMS plans to
expand the program to other theoretically
preventable common diagnoses.8,16
Approximately 30% of stroke patients
expe- rience at least 1 hospital readmission
within 90 days after discharge. 9 A recent
study in this population found that more
than half of 30-day readmissions were
preventable, with more than one-fourth of
patients readmitted because of inadequate
care coordination.17 In addition, only 5%
of the stroke patients readmitted had
outpatient follow-up recom- mended within
a week.17
Individual components of RED have
been shown to decrease rehospitalization
and hos- pital utilization, in addition to
the bundle as a whole.3,12,13 A review of
this literature was the impetus for
implementing this QI project using key
aspects of a transitional care model in our
 The 2 initial components were chosen
steps were in place to establish primary on the basis of the fact that they were
care follow-up appointments and
transmission of discharge summaries for
those with PCPs, the steps were not being
used consistently. In addition, those
patients without PCPs were not
consistently provided with infor- mation
regarding how to establish a medical
home.
As a dedicated primary stroke center,
our neurology team serves stroke patients
throughout our state and discharges these
pa- tients back home to a wide range of
areas. These patients might not be as likely
to return to our center for a subsequent
medical issue because of distance or
resources. This war- ranted a thorough
examination of readmission data back to
the academic medical center as well as to
all other facilities throughout the state.

INTENDED IMPROVEMENT

This project involved enhancing the

exist- ing discharge process for ischemic
stroke pa- tients discharged home with
self-care using nurse navigators. The
primary function of the nurse navigators
was to prevent readmissions in stroke
patients by initially implementing 2
selected key in-hospital RED components
as new interventions on our hospital’s
stroke units.
The 2 selected in-hospital RED
components carried out by our navigators
were making appointments for PCP
follow-up and trans- mitting discharge
summaries.3 Specifically, our navigators
established the PCP follow- up
appointment, transmitted discharge sum-
maries for all patients discharged home
with self-care, and provided primary care
clinic information for stroke patients with-
out PCPs. Our navigators modeled the ac-
tions of the nurse discharge advocates used
in RED through implementation of the 2
se- lected RED components.3 They also
shared RED’s discharge advocates’
underlying goals of coordinating the
discharge plan and prepar- ing the patient
for discharge.3
240 JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2014

successfully completed for patients as part States. These units care for neurology and
of a bundle in RED.3 Also, the neuro- surgery patients and are the primary
interventions were demonstrated to work stroke
independently in other studies as well.12,13
The 2 components were implemented as a
first step in potentially em- ploying more
of the RED bundle in our patient
population.3 These components were also
ini- tially selected on the basis of principles
of the Plan-Do-Study-Act (PDSA) cycle.
This model aims to test change on a small
scale to mini- mize implementation
resistance and to deter- mine whether
desired effects on quality mea- sures are
achieved with certain combinations of
changes.18
One registered nurse (RN) was initially
cho- sen to complete a trial of the 2
components during a 4-month feasibility
phase from Febru- ary to May 2012 to
determine the practicabil- ity of
establishing a navigator role. The nurse
carried out the components that the naviga-
tors subsequently implemented in the inter-
vention. The nurse did so while rounding
with the stroke physician, as this nurse also
functioned as the physician’s outpatient
clinic nurse part of the time. Three
experienced RNs were then chosen to
function in a navigator role permanently
starting in June 2012.

STUDY QUESTION

The study question was as follows: Will

the use of nurse navigators to establish the
PCP follow-up appointment, transmit the
dis- charge summaries for all patients
discharged home and provide primary care
clinic informa- tion for stroke patients
without PCPs, affect 30-day readmissions
and hospital utilization when compared to
the standard discharge process?

METHODS

Setting
This project was implemented on 2
neuro- science units in a 700-bed academic
medical center in the Southeastern United
units. The project sample included all patient’s PCP and documented on a
is- chemic stroke patients who were “Stroke Discharge Navigation Form” prior
discharged home with self-care (not to to each patient’s discharge. Navigators
a rehabilitation unit or skilled nursing men- tioned key components to patients
facility) beginning June 2012 through regarding
September 2012. The institu- tional
review board at the academic medical
center approved this QI project.
Care delivery
Standard of care
The standard of care for ischemic
stroke patients discharged home with
self-care prior to the discharge
intervention involved the fol- lowing
process. The physician completed the
discharge paperwork and provided it to
the secretary for copies and scheduling.
Secre- taries made specialty
appointments and faxed necessary
information for those appoint- ments,
but this did not occur as a standard pro-
cess for PCP appointments. If the
patient had a PCP, the discharge
paperwork instructed the patient to
“follow up in 7 to 10 days” with the
PCP and no appointment was
scheduled. If the patient did not have a
PCP, the discharge paperwork stated
“patient to establish.” When a patient
was discharged home with self-care,
the discharge summary was faxed to
the PCP through an automated hospital
system. How- ever, this was dependent
on the PCP being in- dicated on the
discharge summary. Finally, the RN
caring for the patient that day received
the paperwork and instructed the
patient about the appointment
information as written on the discharge
paperwork.
Intervention
Nurse navigators made contact with
each is- chemic stroke patient being
discharged home with self-care prior to
discharge. Naviga- tors provided
unbiased lists of free and fed- erally
funded clinics or lists of providers
through insurance links and
encouraged the patients to select a PCP
if they did not have one. Navigators
then ensured that a PCP follow-up
appointment was scheduled with the
 Stroke Discharge Advocacy to Reduce Readmission
Rates 241
Ninth Revision (ICD-9) codes, discharge
follow-up including emphasizing dis- position, and discharging hospital.
adherence/ importance of the scheduled Character- istics entered into the system to
appointment, confirming appointment collect the ap-
location, contact number, and verbalizing a
transportation plan to that appointment.3
Navigators gave a brief verbal report of the
patient’s hospital course if possible to the
PCP office and ensured transmission of the
discharge summary to this office.3
The intervention continued to evolve
through the PDSA process, and navigators
added 2 additional RED components in the
final month of the intervention (September
2012).18 These 2 additional interventions
ed- ucated patients about relevant
diagnoses and confirmed the medication
plan.3 Navigators began providing tailored
education to each patient on the basis of
their diagnosis of is- chemic stroke.
Tailored education focused on self-care,
the importance of obtaining and tak- ing
medications, the importance of calling 911,
and stroke risk factors and warning signs to
prevent stroke recurrence or severity of
recurrence. Navigators ensured that this
edu- cation occurred during their contact
with pa- tients prior to discharge and
documented this on the “Stroke Discharge
Navigation Form.”

Methods of evaluation
A comparative design was used to evalu-
ate the measure for this project, 30-day
read- mission rates. Additional measures
and data points collected were 30-day
emergency de- partment (ED)/observation
visits. Outcome measures were
readmission and hospital uti- lization data,
currently collected by the state’s Office of
Research and Statistics. No identify- ing
data or demographics were collected on
any patient, and only aggregate data of a
to- tal number of readmissions or
ED/observation visits compared with
discharges were col- lected. Data
collection fidelity was ensured through use
of the state’s Office of Re- search and
Statistics data collection system that tracks
patients by their diagnosis us- ing
International Classification of Diseases,
 with postintervention data (Fig 1).
propriate data included diagnosis of
ischemic stroke, discharged home with
self-care from the academic medical
center, a readmission, or ED/observation
visit within 30 days to any state hospital
for any diagnosis. Initial prein- tervention
data were collected for 24 months to
establish a baseline. A feasibility phase
was then carried out for a period of 4
months, fol- lowed by the implementation
of the evidence- based revised discharge
process.

Analysis
Preintervention, feasibility phase, and
post- intervention 30-day readmission rates
were examined. In addition, 30-day ED
rates were evaluated. Measurement of
outcomes in- cluded the average ischemic
stroke readmis- sion and ED/observation
rates for the 24 months prior to the
intervention compared with the rates for
the months postinterven- tion. Analysis
was completed using Microsoft Excel
2011.

RESULTS

Readmission outcomes
During the February 2010 to January
2012 preintervention time frame, an
average of
20.8 patients were discharged each month.
The average 30-day readmission rate to all
state hospitals was 9.80% (readmissions to
all state hospitals are inclusive of
readmissions to our hospital). The average
30-day readmis- sion rate to our hospital
was 9.39%. During the February 2012 to
May 2012 feasibility phase, an average of
19.3 patients were discharged each month.
The average 30-day readmission rate to all
state hospitals and our hospital was 2.63%.
During the June 2012 to September 2012
postintervention time frame, an average of
21.3 patients were discharged each month.
The average 30-day readmission rate to all
state hospitals and our hospital was 3.24%.
Improvements were seen in 30-day
readmission rates when comparing pre-
242 JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2014

Emergency department and observation
visit outcomes
ED and observation visits reflect the per-
centage of patients discharged from our hos-
pital who were seen for an ED or obser-
vation visit within 30 days after discharge
at any state hospital. During the prein-
tervention time frame, the average 30-day
ED/observation visit rate to all state hospi-
tals was 16.36% and was 6.90% to our hos-
pital. During the feasibility phase, the av-
erage 30-day rate to all state hospitals was
12.11%. The average rate to our hospital
was 6.80%. During the postintervention
time frame, the average 30-day
ED/observation visit rate to all state
hospitals was 12.08% and was 4.24% to
our hospital. Improve- ments were seen in
30-day ED/observation visit rates to all
state hospitals when comparing pre- with
postintervention data (Fig 2). ED visits to
our hospital were likewise decreased.

Figure 1. Thirty-day readmissions: pre- versus

postintervention.

Figure 2. Thirty-day ED/observation visits: pre- versus postintervention. ED indicates emergency

depart- ment.
 Stroke Discharge Advocacy to Reduce Readmission
Rates
DISCUSSION
The results of this QI project indicate
that when nurse navigators use an
evidence- based transition of care process,
ischemic stroke patients discharged home
had de- creased readmissions and hospital
utiliza- tion. When nurse navigators
established PCP follow-up appointments,
established PCPs for those without
providers, and ensured trans- mission of
discharge summaries to PCPs in the
ischemic stroke population, reductions
were seen in readmissions to our hospital
and in ED/observation visits to all state
hospitals. These interventions,
implemented both col- lectively and
individually, have been shown to be
effective in other general populations and
heart failure populations, and translated
well into our population.3,12,13
The data collected allowed us to gain a
bet- ter understanding of the distribution of
our readmissions and hospital utilization.
Prior to this project, it was anticipated that
many of our readmissions were to other
state hospi- tals. This was not the case, as
the majority of our readmissions were to
our hospital. This was not true for hospital
utilization, however, as many of our
patients were using other state hospitals,
likely closer to their homes, for visits to the
ED. These variations may result from cases
in which recently discharged ischemic
stroke patients who required readmission
were sent back to our hospital because of
the level of care they needed. In
addition, the findings indicating that the
greatest impact on hospital utilization was
at other state hospitals were likely because
these other hospitals are often in rural and
underserved areas, whereas our facility has
more resources. Aligning patients from
these areas with medical homes potentially
allowed for patients to consult PCPs about
outstanding issues rather than visit the ED.
This outcome
REFERENCES
243
is encouraging, as it successfully addresses
a portion of the challenge facing our
nation’s health care in regard to costly
hospital uti- lization, particularly in rural
and underserved areas.
Limitations
While the feasibility phase of this project
was an attempt to lay the groundwork for
change in the discharge process, it led to a
lower rate of readmissions during that
time. This lower rate could be the result of
1 nurse rounding with the physician and
doing the majority of the work during the
feasibility phase. This presence during
rounds could have allowed the nurse to be
aware of out- standing follow-up issues or
barriers, leading to subsequent
predischarge intervention.
CONCLUSIONS
This project supports the evidence-based
transition of care discharge process and
demonstrates its effectiveness in decreasing
readmissions and hospital utilization in the
is- chemic stroke population. Nursing
implica- tions for this project include the
immense im- pact of using nurses as
navigators and patient advocates through
the health care system, par- ticularly when
transitioning from acute care to the home
setting. Organizations considering
implementing navigator roles should exam-
ine cost-effective ways to incorporate these
functions into existing positions by diversi-
fying current roles. This may help alleviate
financial strain associated with adding new
positions, allowing for more systematic ex-
pansion into established full time roles. Fu-
ture research should examine the longevity
and financial impact of these findings in
this population as well as the effect of
navigators rounding permanently with
physicians for in- creased continuity.
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