Wisconsin Coverdell Stroke Program: Stroke Systems of Care

The Joint Commission has defined transitions in patient care as "the movement of patients between health care practitioners, settings, and home as their condition and care needs change." A key goal of the Wisconsin Coverdell Stroke Program is to create efficiencies in patient care transition 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.

Graphic depicting Coverdell Care Continuum

The Joint Commission's Transitions of Care: The Need for a More Effective Approach to Continuing Patient Care seeks to provide guidance for improving the effectiveness of patient transition between health care organizations. The document outlines focus areas for improvement of care transitions and identifies the root causes of ineffective transitions of care.

Areas of Focus

The following areas of focus related to improving care transitions have been identified by The Joint Commission, and adopted by the National Centers for Disease Control and Prevention (CDC) and the Wisconsin Coverdell Stroke Program. Researchers and providers agree that improvement and increased understanding in these areas will lead to improved patient outcomes.

  • Evaluation of transitions of care measures
  • Identification of the root cause of patient 30-day readmissions
  • Clinician involvement and shared accountability
  • Multidisciplinary communication, collaboration, and coordination
  • Comprehensive planning and risk assessment throughout hospitalization
  • Standardization of transition plans, procedures, and forms
  • Standardization of training and education
  • Timely follow-up, support, and coordination after a patient leaves a care setting

Root Causes of Ineffective Care Transitions

In addition to providing the focus areas detailed above, The Joint Commission 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 focus areas and root causes can be found in Transitions of Care: The Need for a More Effective Approach to Continuing Patient Care by The Joint Commission.

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 February 2, 2021):

  • Ascension Columbia St Mary's Ozaukee
  • Ascension Columbia St. Mary’s Milwaukee
  • 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 E Wisconsin Mercy Campus
  • 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 Manitowoc County
  • Aurora Medical Center Summit
  • Aurora Medical Center Oshkosh
  • Aurora Memorial Hospital of Burlington
  • Aurora Sheboygan Memorial Medical Center
  • Aurora Sinai Medical Center
  • Aurora St. Luke's Medical Center
  • Aurora St. Luke's South Shore
  • Bellin Memorial Hospital
  • Essentia Health-St. Mary's Hospital of Superior
  • Froedtert  & the Medical College of Wisconsin
  • Froedtert West Bend
  • Gundersen Health System
  • 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 February 2, 2021):

  • Ascension NE Wisconsin Mercy Campus
  • Ascension NE Wisconsin St. Elizabeth Campus
  • Ascension SE Wisconsin Hospital - Elmbrook Campus
  • Ascension SE Wisconsin Hospital - St. Joseph Campus
  • Aspirus Langlade Hospital (Antigo)
  • Aspirus Medford Hospital and Clinics
  • Aspirus Wausau Hospital
  • Bellin Memorial Hospital
  • Froedtert and the Medical College of Wisconsin
  • ProHealth Oconomowoc Hospital
  • ProHealth Waukesha Memorial Hospital
  • The Richland Hospital, Inc.
  • 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

Publications

Website Resources


Logo for the Wisconsin Coverdell Stroke ProgramMore Information:
Dot Bluma, BSN, RN, CPHQ
Stroke Project Specialist, MetaStar
dbluma@metastar.com

Last Revised: February 4, 2021