Recent stroke care developments may be encouraging
by Liz Carey
May 7, 2018

How are homecare services changing to meet the diverse needs of stroke patients?

About 70 percent of stroke patients navigate deficits in activities of daily living (ADLs) after stroke. Common physical disabilities that lead to potential risks after stroke include difficulty walking, balance issues, weakness in arms and legs and swallowing difficulties. These disabilities increase the risk of falls. And these are just a few of the considerations.

Many after-stroke patients live with cognitive deficits that impair the person’s abilities to think clearly. Related to cognitive deficit includes delirium (acute confusion due to medical issues), and safety risks due to challenges making good decisions. Additionally, depression is a problem.

“Over the past 10 years, investigators and homecare services all over the world have been working to transition stroke patients to home sooner and ensure better rehabilitation,” said Dr. Michael Cantor, geriatrician and chief medical officer for CareCentrix, a company that coordinates care and connects service providers with payers. The model that has the best evidence of its effectiveness is known as "early supported discharge" (ESD).

Cantor describes ESD as multidisciplinary teams working in hospitals and rehabilitation facilities to reduce the length of inpatient stay, and discharge home sooner, where patients are followed by a community-based team that provides comprehensive rehabilitation for patients and may include home-based rehabilitation, group classes and caregiver training and support. A recent Cochrane review of the literature found that ESD can reduce hospital length of stay for stroke, and make it less likely that the patient will have long-term dependency and need ongoing institutional care. “The key to success depends on having a coordinated team to manage the patient at home.”

Volumes of Ideas

Stroke appears numerous times in a new collected volume of Center for Medicare & Medicaid Innovation (CMMI) stakeholder input that focuses on new directions to promote patient-centered care and test market-driven reforms. Innovative care models (some in progress since 2010 when the Innovation Center launched) are one of the ways stroke and after-stroke care is enhanced today.

The American Academy of Neurology (AAN) is the premier national medical specialty society representing more than 32,000 neurologists and clinical neuroscience professionals. A neurologist is a physician with specialized training in diagnosing, treating and managing disorders of the brain and nervous system, including stroke. New directions pursued should not come at the expense of existing models, the AAN told CMMI.

Telemedicine, Telehealth, Telestroke

The American Medical Rehabilitation Providers Association (AMRPA) presented eagerness to work with the Innovation Center to discuss how its Continuing Care Network (CCNet) collaborative model could be adopted to meet CMS’s parameters for test models. The association described this model as a choice for Medicare Advantage enrollees who have experienced a stroke and have been discharged from an acute hospital setting.

“This approach aligns with the broader evolution in health care of moving toward unified payments that assess outcomes based on both total quality and costs of care,” AMRPA offered in the CMMI document, and the approach, which includes home health agencies (HHAs), intends to break down the current silos and enable innovation around telemedicine.

The pursuit of telemedicine, telehealth and telestroke plays a role in innovative care models. The Furthering Access to Stroke Telemedicine (FAST) Act of 2017 (HR 1148, S 431) intended to expand the use of telehealth in Medicare for stroke cases. Translated into telestroke, such a measure is seen as one way to help improve rural health care, as well as expand, enhance and cost-save for health care overall.

By way of the CHRONIC Care Act, beginning in 2019, the existing geographic restriction (the origination site requirement) for telemedicine physicians will be eliminated. Additionally, with new nationwide coverage for telestroke and enhanced telehealth coverage for ACOs (accountable care organizations), states across the U.S. have been busy changing their laws toward the pursuit of telehealth.

A Priority Condition

American Speech-Language-Hearing Association professionals treat speech sound and motor speech disorders, cognitive disorders and swallowing (dysphagia) deficits, among others, related to conditions that include stroke. Included in CMMI’s April 2018 document, ASHA requested the expansion of the scope of alternative payment models (APMs) from “Physician Specialty Models” to “Condition/Procedural Models,” as “the latter will more accurately capture the contributions of the entire care team.”

Stroke, which is a leading cause of disability, has been identified as a “priority condition” due to its prevalence, expense and relevance to health policy. Stroke care is said to be prime for clinical innovation and delivery reform, with secondary prevention critical in avoiding further deficits to a patient’s motor, cognitive and emotional status and for avoiding unnecessary health care and disability expenses. 

Working toward a solution is the Outpatient Stroke Care Coordination Model of Texas not-for-profit Baylor Scott & White Health (BSWH), which operates 48 hospitals, 160 primary care clinics, and nearly 500 specialty clinics, and in 2018 plans to open a new neuro transitional rehabilitation center.

Baylor’s stroke care coordination model designates stroke coordinators, using a customizable software platform to track patient flow, contact all patients with a primary diagnosis of stroke or mini-stroke within 48 hours of discharge, and the stroke care model is funded using the transitions of care management fee code/model. Among many coordinator duties involves reviewing discharge care, and the goal of the program is to increase follow-up care and ensure patients are taking prescribed medications.

To CMMI, Baylor describes a flexible care plan operating as part of a 90-, 180- or 365-day capitated payment for services not traditionally reimbursed under fee for service (FFS) other than care coordination. Services may include shuttles, meals and exercise classes, and clinicians would have a high degree of autonomy on how to use funding, similar to how the chronic care management (CCM) and care transition codes work, to support innovations that work for their patient populations and market structures. CMMI, through its Medicare Advantage Value-Based Insurance Design Model, is already experimenting with benefit designs for select plans for enrollees with past stroke, among other conditions. Plans may offer additional wrap-around services that have been identified as leading to improved clinical outcomes, according to the Healthcare Financial Management Association (HFMA).

“There are many groups in stroke centers and rehabilitation programs across the country looking to improve outcomes after stroke,” CareCentrix’s Cantor said. He points to the COMprehensive Post-Acute Stroke Services (COMPASS) study in North Carolina, which planned to evaluate the impact of having a nurse practitioner and post-acute care coordinator assess stroke patients and their caregivers, and develop care plans for stroke patients discharged home.

“Stroke patients have diverse needs, and the impact of stroke varies significantly from person to person,” Cantor said. Seventy-percent of stroke patients fall within six months of their stroke, as well as have problems due to pneumonia, and eating and swallowing, he said.

“Our understanding of how to prevent stroke and reduce the risk of additional strokes has improved a lot,” Cantor said. “In addition to ESD, there are a lot of technological tools being deployed, ranging from tablet-based apps to support rehabilitation, remote physical therapy, and even robots to assist with therapy. Interesting technologies are on the horizon that will make it easier for patients with stroke to overcome deficits from strokes, as well as to enhance rehabilitation and ongoing restorative treatments. Advances in communication technologies are also helping to make collaboration easier for patients, family caregivers and health care professionals.”

As of March 1, 2018, the CMMI (Center for Medicare & Medicaid Innovation, Innovation Center) had implemented 37 models, obligating $5.6 billion, to test new approaches for delivering and paying for health care with the goal of reducing spending and improving quality of care.

Learning More:
Access the CMMI document.

Assistive technologies for seniors who have had a stroke.

Telemedicine's legal landscape.

Highlights of the new Iowa telehealth law.