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Creating Stroke Systems of Care

Elyas Bakhtiari, for HealthLeaders Magazine, June 9, 2010
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Ideally, the increase in basic stroke patients at the spoke hospital and complex ones at the hub help both service lines grow.

Success Key No. 2: Figure out reimbursement
Physician buy-in is absolutely essential to pulling off a telestroke network, Livesay says. While early communication and other physician relations strategies are important to getting doctors onboard, reimbursement is a major concern that can't be overlooked.

However, the guidelines for telestroke reimbursement are still inchoate and tough to interpret. St. Luke's researched several different models when setting up its network.

One option is a sort of fee-for-service model between the spoke hospital and the on-call physicians where the doctor receives a predetermined payment for every connection he or she makes with the spoke hospital. Some spoke hospitals instead prefer to pay the physicians a flat monthly or yearly fee for their telestroke services. In other cases, the spoke hospitals don't bill at all and let physicians handle their own reimbursement for the services.

There are benefits and drawbacks to each approach, and the best fit depends in part on individual preferences and whether the physicians are employed or in private practice. Most doctors, for example, don't like to bill for their own telestroke services because there can be so much variation among payers.

Baylor College of Medicine physicians contract with spoke hospitals for a yearly fee that covers telestroke consultations. This is all set up directly between the physicians and the spoke hospital, says Livesay. St. Luke's has a transfer agreement with the spoke hospitals, but aside from research into various models and overall support, doesn't get directly involved in reimbursement negotiations.

"We spent a lot of time trying to work through the details of billing and compliance issues," says Boyd. "That's a market that's changing regularly."

Success Key No. 3: Don't overinvest in technology
A few decades ago, building these regional systems of care wouldn't have been as easy. Technology, and telestroke in particular, has enabled the entire movement toward systems-based care to take place.

But hospitals should avoid placing too much emphasis on the technology elements of the program, says Connie L. Boyd, service line director for neurosciences and oncology at St. Luke's. A secure laptop and webcam setup is all that St. Luke's needs to coordinate with spoke hospitals, she says.

Some software and hardware packages require large investments, which a lot of smaller hospitals may not be able to make. That's why St. Luke's purposefully decided that technology would not be the primary focus when it began exploring telemedicine.

"Don't jump too quickly," Livesay cautions. "The market is changing rapidly. The technology and software packages are going to look different in several years."

Instead, focus on a few basic questions: Is it secure? Is the connection reliable? Can providers share necessary information?

More advanced telestroke systems that incorporate robots and other high-end technology are certainly an option for the systems that can afford them. But it's important to remember that even the best technology will fall short if leadership doesn't build the infrastructure and relationships to make the network work, says Livesay.

Success Key No. 4: Seek certification
As more regional networks begin to spread, each facility has to determine its desired role as a stroke care provider within a larger system. Being a hub hospital sounds like a nice volume driver, but becoming a comprehensive center takes a lot of investment in technology and specialists. Even primary center certification can be a tall order for hospitals without existing stroke programs.

"As a hospital CEO, you have to decide for your own community what the market looks like, identify the other stroke centers, and recognize that it is an investment to become a primary stroke center," says Sacco.

But as more states add certification requirements that allow EMS diversion, getting certified as a primary stroke center—either by The Joint Commission, a state agency, or an organization like DNV Healthcare—may become a necessity.

Certification isn't just another hoop to jump through, however. Programs that meet the various requirements for primary stroke center certification tend to have better-quality results and higher-performing teams.

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