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Creating Stroke Systems of Care

Elyas Bakhtiari, for HealthLeaders Magazine, June 9, 2010
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If U.S. healthcare is headed toward a model that eliminates fragmentation and emphasizes continuity and cooperation, stroke care may be leading the way and making a difference in patients' lives.

A few years ago an American Stroke Association task force set a new bar for stroke care delivery: Successful treatment of stroke can't be thought of as a single inpatient procedure. Instead, stroke care should be provided in a system that involves coordination along the entire care continuum, from primary prevention through rehabilitation.

Stroke is a complex and time-sensitive disease that requires equally complex approaches to treatment. Although there have been major advances in clinical treatments in recent years, the best medicine matters little if the patient doesn't get treatment fast enough to prevent death or disability. And although many hospitals have improved the speed and coordination of their own care teams, many patients live too far away to reach the best stroke centers in time.

Individually, advances in treatment and in care delivery will do little to stem the tide of stroke mortalities unless hospitals and physicians can put all the pieces of the puzzle together.

"For us to be successful at really achieving the goals of reducing death and disability from stroke, we have to look across the whole system," says Ralph Sacco, MD, president-elect of the American Heart Association and chair of neurology at the University of Miami Miller School of Medicine.

The ASA estimates that if every state had stroke systems of care in place, the country could make significant progress toward the organization's 2010 impact goal to achieve a 25% reduction in coronary heart disease, stroke, and risk.

One of the most challenging steps in building that type of system can be creating a network for acute and sub-acute care. It's not efficient to have all the capabilities of a comprehensive stroke center (which provides interventional and high-tech stroke treatments) at every hospital, says Sacco. Instead, stroke centers are developing into hub and spoke networks that help extend advanced stroke care to regions that otherwise wouldn't have the resources.

For instance, in a properly designed system, a patient in a rural area without a comprehensive stroke center would only have to worry about getting to the nearest hospital once symptoms start. That spoke hospital would have access to on-call neurologists at a hub, via telemedicine, and could then stabilize the patient. If the stroke required more complicated intervention, the patient would then be transferred to the comprehensive center.

Building these networks requires more than technology, however. Numerous leadership challenges accompany coordination between several (sometimes competing) hospitals. But hospitals large and small, as well as patients and providers, will ultimately benefit if they can achieve the teamwork needed to create a true system.

Success Key No. 1: Build beneficial partnerships
St. Luke's Episcopal Health System, a four-hospital system based out of Houston, was an early adopter of the stroke center model, receiving its first Joint Commission certification in 2004 and upgrading to a comprehensive center in subsequent years. To expand the program, leaders recently signed agreements with five hospitals outside of the system that will serve as spokes in St. Luke's stroke care network.

St. Luke's was motivated to build the network by two characteristics of the local market that mirror nationwide trends in stroke care. The first was simply struggles in rural physician recruitment. "We were approached by several hospitals in rural areas interested in taking care of stroke patients but struggling with the acute management of those patients in emergency room ... They didn't have the neurological and the neurosurgical support to care for the more acute patients," says Sarah Livesay, manager of neuroscience clinical programs at St. Luke's.

The second factor was related to legislation that the state of Texas was considering that would encourage patients to receive care at certified stroke centers. Several states and cities across the country have passed or are considering similar laws, which generally allow emergency medical services to take patients to the nearest certified hospital, bypassing a closer hospital that doesn't have the qualifications (if they have time).

Because of the legislative pressure, rural hospitals lacking the physician support for 24/7 stroke coverage were faced with the prospect of losing stroke patients if they didn't improve their programs. Becoming a spoke in St. Luke's network helped solve this problem. Thanks to telemedicine, St. Luke's physicians can provide around-the-clock consultative call coverage to partner hospitals.

Livesay says this mutually beneficial relationship is essential to building a successful system. "We make it clear from the get-go that we're not taking all their stroke patients or keeping them from growing. By partnering in this relationship it will help them grow their service line."

Because private practice neurologists in smaller communities are increasingly reluctant to take call, the telestroke coverage from a hub allows smaller hospitals to maintain good physician relations while still keeping up stroke volume. St. Luke's has three neurocritcal care intensivists to provide that coverage at Baylor College of Medicine in Houston.

If the spoke hospital is able to successfully treat the patient using only the telestroke assistance, then the patient stays put. But the moment that the severity of the stroke patient exceeds the spoke hospital's capabilities—if the patient requires neurosurgical intervention or post-tPA management, for example—he or she can be transferred to St. Luke's for more comprehensive treatment.

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