Wisconsin Coverdell Stroke Program: Stroke Systems of Care
The American Stroke Association (ASA) describes the following elements as transitions within a stroke survivor’s system of care: “from prehospital to the admitting hospital, from the intensive care unit to the hospital floor, from the hospital to post-acute settings (inpatient rehabilitation, skilled nursing facility, long-term acute care hospital, or home), and from a facility to home.” A key goal of the Wisconsin Coverdell Stroke Program is to create efficiencies in patient care transitions in Wisconsin. To address this priority, the program is partnering with stakeholders to create stroke systems of care guidelines and best practices as illustrated in the graphic below.
The ASA’s Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update seeks to provide guidance for policymakers and public healthcare agencies to update their stroke systems of care. These revisions should be based on ASA’s comprehensive review of scientific evidence, evaluating current stroke care, and updates to the ASA’s previous recommendations for improvements in stroke systems of care.
Recommendations for improving Stroke Systems of Care
The following areas of focus related to improving care transitions and reducing disparities in stroke care have been identified by the ASA and the Wisconsin Coverdell Stroke Program. Researchers and providers agree that improvement and increased understanding in these areas will lead to improved patient outcomes.
- Further advance public knowledge on prevention, risk factors, and signs and symptoms of stroke
- Encourage primary prevention with a particular focus on earliest (primordial) risk factors that can lead to stroke
- Improve and facilitate acute therapy
- Advance secondary prevention and recovery from stroke
- Develop stroke programs in a coordinated and collaborative fashion, involving providers and policy makers at the local, state, and national levels
Root causes of ineffective care transitions
In addition to providing the focus areas detailed above, the ASA has identified three primary root causes of ineffective transitions of care. Root causes often differ from one health care organization to another, but those most often described in medical literature and by experts include:
- Communication breakdowns
- Patient education breakdowns
- Accountability breakdowns
More details about these recommendations can be found in Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update by the ASA.
Care continuum
The aims of the WI Coverdell Stroke Program are to support the implementation of comprehensive stroke systems for individuals, both at highest risk for stroke events and for stroke patients, across the continuum of care. The keys to any successful patient transition across the care continuum are establishing partnerships, open communication and assessing accountability. Get With The Guidelines®, the stroke registry into which participating hospitals enter stroke abstracts, has capabilities to capture the care continuum in the pre hospital (Special Initiatives), in hospital, and post discharge (Discharge, Mortality & Readmission) settings. This data infrastructure allows hospitals to (1) measure, track, and assess the quality of stroke care data and (2) implement performance improvement initiatives to ensure seamless transitions of care.
The Wisconsin Coverdell Stroke Program offers support for improving overall stroke care across the care continuum by running data from Get With The Guidelines® and providing quarterly report cards with comparative benchmarks for hospitals to analyze their performance. Coverdell also holds quarterly meetings where we analyze and discuss data across the care continuum. These meetings also allow for networking and best practice sharing.
While not mandatory, Coverdell participants are highly encouraged to consider the benefits and feasibility of entering data into Get With The Guidelines® free Special Initiatives and Discharge, Mortality & Readmission care tabs. This allows for assessment of post-hospital discharge activities for improved, comprehensive care, across the entire continuum.
The following WI Coverdell participating hospitals are entering pre-arrival metrics in the Special Initiatives tab (as of April 1, 2022):
- Ascension NE Wisconsin St. Elizabeth Campus
- Ascension NE Wisconsin Mercy Campus
- Ascension SE Wisconsin Hospital - Elmbrook Campus
- Ascension SE Wisconsin Hospital - Franklin Campus
- Ascension SE Wisconsin Hospital - St. Joseph Campus
- Ascension St. Francis Hospital
- Aspirus Grand View Hospital (Ironwood)
- Aspirus Iron River Hospital and Clinics
- Aspirus Keweenaw Hospital
- Aspirus Langlade Hospital (Antigo)
- Aspirus Ontonagon Hospital
- Aspirus Riverview Hospital and Clinics
- Aurora Medical Center Grafton
- Aurora Medical Center Oshkosh
- Aurora Sheboygan Memorial Medical Center
- Aurora St. Luke's Medical Center
- Bellin Memorial Hospital
- Froedtert & the Medical College of Wisconsin
- Froedtert Menomonee Falls
- Froedtert West Bend
- Gundersen Health System
- Marshfield Medical Center-Ladysmith
- ProHealth Care Oconomowoc Memorial Hospital
- ProHealth Care Waukesha Memorial Hospital
- The Richland Hospital, Inc.
- ThedaCare Regional Medical Center-Neenah
- University of Wisconsin Hospital & Clinics
The following WI Coverdell participating hospitals are entering post discharge metrics in the Discharge, Mortality & Readmission tab (as of April 1, 2022):
- Ascension SE Wisconsin Hospital - Elmbrook Campus
- Aspirus Langlade Hospital (Antigo)
- Aurora St. Luke’s Medical Center
- Bellin Memorial Hospital
- Froedtert and the Medical College of Wisconsin
- ProHealth Oconomowoc Hospital
- ProHealth Waukesha Memorial Hospital
- SSM Health St. Mary’s Hospital-Madison
- University of Wisconsin Hospital & Clinics
The Wisconsin Coverdell Stroke Program partners with various stakeholders, both at the state and national level, to continue to increase the quality and efficiency of patient stroke care across the care continuum.
Additional resources
Articles, guidelines, and webinars
- GWTG® Coverdell Post Discharge, Mortality & Readmissions Tab Webinar Recording
- Taking an Accurate Blood Pressure Reading – Outpatient Adults. A guide for teaching staff how to take an accurate blood pressure.
- Patient Self-Measurement of Blood Pressure. A guide for teaching patients how to self-monitor their blood pressure at home.
- Million Hearts® Tobacco Cessation Change Package (TCCP)
- ImageTrend Connect: The Value of Data
- Social Determinants of Health and Stroke Series
Publications
- Follow-Up Call Resource Guide: Bridging Transitions of Care for Stroke Survivors after Hospitalization, P-02601 (PDF)
- Stroke Follow-Up Call Triage Algorithm P-02361 (PDF)
- Empower People with Knowledge: Community Outreach Stroke Awareness Event Planning Toolkit, P-01861 (PDF)
Website resources
- Wisconsin Coverdell Stroke Program BE FAST Community Education
- Wisconsin Coverdell Stroke Program—Hospitals
- Wisconsin Coverdell Stroke Program—EMS
- Wisconsin Hospital Association—Stroke Systems of Care Collaborative
- CDC Paul Coverdell National Acute Stroke Program
More Information
Dot Bluma, BSN, RN, CPHQ
Stroke Project Specialist, MetaStar
dbluma@metastar.com