Stroke Patient Transitions of Care ToolkitMINNESOTA STROKE PROGRAM2/20/2019

For questions about transitions of care for stroke patients, contact:Minnesota Department of HealthStroke Program, Cardiovascular Health UnitPO Box 64882St. Paul, MN 55164-0882(651) mn.usTo obtain this information in a different format, call: 651-201-4093. Printed on recycled paper.2

Table of ContentsChapter 1: Introduction . 4Chapter 2: Project Planning Steps . 6Step 2: Build Team of Key Players. 9Step 3: Schedule Meetings. 12Step 4: Identify Areas for Improvement . 12Step 5: Prioritize areas for improvement . 17Step 6: Action plan development and implementation . 17Chapter 3: Transitions of Care QI Project Ideas. 201. Transition from Hospital to Home . 202. Transition to Community and Post-discharge follow-up . 233. Provider Education. 254. Patient and Caregiver Education and Engagement . 265. Medication Reconciliation and Management . 27Chapter 4: Post-discharge Follow-up and Data Collection . 29Resources and References . 32Appendix 1: MDH Learning Project: Transitions of Care for Stroke Patients . 40Appendix 2. Flow Map . 43Tools and Templates . 44Stakeholder Analysis Matrix Worksheet. 45Members Roles and Responsibilities Worksheet . 46Criteria for Selecting Process Improvement Opportunities . 47Multi-voting Technique. 49Process Flow Map . 51Swim Lane Process Map . 53Touch Points after Stroke . 54Project Work Plan: Transitions of Care Project Name . 55Stroke QI Transitions of Care Initiative Project Plan. 56PDSA Worksheet for Testing Change . 573

Chapter 1: IntroductionTransitions of Care is the movement of patients among providers, different goals of care, andacross the various locations where health care services are received. The goal of transitionmanagement is to facilitate and support seamless transitions across the continuum of care. It isalso to achieve and maintain optimal adaptation, outcomes, and quality of life for patients,families, and caregivers following a medical event – such as a stroke.In the past decade, Minnesota has made significant progress improving emergency treatment andinpatient care for acute stroke patients. However, the transition back home for these patientsremains difficult. After a stroke, patients may experience physical, emotional, cognitive, and socialcomplications. Poorly executed health care transitions increase the risk of medical complications,poor patient outcomes, and caregiver stress. Going home with a new disability raises concerns forhealth challenges and ultimately readmission to the hospital. Studies show that interventions likeclose coordination of care, along with early follow-up care after hospital discharge, reduce the rateof complications leading to readmission.Transitioning patients between care settings starts in the hospital and requires coordinationbetween health professionals. This coordination ensures that the patient’s health and personalneeds are met. Creating a smooth transition for stroke patients from hospital to their homes andcommunities is vital. It requires building internal connections that branch out between hospitals,rehab facilities, home care agencies, clinics, and community-based organizations. Hospitals play apivotal role in ensuring the transition for patients to home is smooth.Purpose of ToolkitThe purpose of this toolkit is to provide resources for staff at hospitals and other health facilities tohelp implement strategies to improve the transition for stroke patients from hospital to home. Thistoolkit provides tips, tools and resources for implementing these strategies.The toolkit is organized into the following sections:1. Project planning steps (Chapter 2)2. Quality improvement project ideas (Chapter 3)3. Post-discharge follow-up and data collection (Chapter 4)4. Resources and References5. Appendix (Templates and Tools)4

Throughout this toolkit you’ll see tips, examples, and references to tools that are ready-to-use.Tips and Ideas are in Yellow boxesExamples are in Blue boxesTemplates are at the end – find links to them in Green (Blank Template: PDSA Worksheet)On the Minnesota Department of Health Stroke Program Resources web site, you can find:-This toolkitDownloadable (ready-to-use) tools (Microsoft Word documents)Examples (completed samples) of various tools found in this toolkit.To find these resources, go to: Minnesota Department of Health Stroke Program (

Chapter 2: Project Planning StepsThe following are steps that a hospital would likely follow to plan and implement a careimprovement project for stroke patients transitioning from hospital to home. These can be adaptedto meet the needs of your organization.Secure Buy-inSelect theimprovment(s)/PrioritizeImprovementsSchedule MeetingsBuild Team of KeyPlayersFind Problems orProcesses NeedingImprovementImplement projectsThese steps are: Buy-in, Engagement and OwnershipBuild a Team of Key PlayersSchedule MeetingsIdentify Areas for ImprovementPrioritize Areas for ImprovementAction Plan Development and ImplementationStep 1: Secure Buy-in, Engagement and OwnershipWhen starting a transitions of care project for stroke patients, it is important to secure “buy-in” onan organizational level and from the individuals that you would like to participate in the project.Once individuals have bought into the project, then they can take ownership in it!Securing buy-in may be challenging. A project usually starts with a personbeing really excited about A GREAT IDEA that will lead to change.Getting StartedIn order to secure buy in it is important to clarify your ideas about thechange you want to see in your organization’s practice before talking toothers.1. Identify rationale/need for change. Put into writing how you came up with your idea and thereason you want to do it.Example: You notice that not all TIA patients receive follow-up calls from the hospital and youwould like to start a quality improvement project to improve this. You think it will improvepatient satisfaction and reduce future emergency department visits.6

2. Investigate current practices. As you think about a project, you need to understand currentpractices in order to identify areas that require improvement.Example: You have noticed that patients are not aware of their personal risk factors when theycome back to the clinic for follow-up care and you wonder why this is.- Individualization of stroke risk factors supports secondary prevention of stroke. Currentpractice provides a generic list of risk factors that are not specific to the patient. How canthis be improved?Organizational and Individual Buy-inAs you implement your quality improvement projects, barriers you encounter will require patienceand individual buy-in while others may require the influence of executive leadership. Beyondsimply removing barriers, having support and engagement from your senior leaders can helpfacilitate change.ORGANIZATIONAL/INDIVIDUAL BUY-INOrganizational buy-in is needed for most projects to be successful. This means securing leadershipsupport from your hospital, health system or clinic. Identify which member of leadership would be most appropriate to partner with. Who isfamiliar with the processes and policies related to stroke transitions of care.(e.g., CNO, CFO,or Director)? Discuss allocation of resources and time needed to drive plan forward. (e.g., resources,time, and moral support) Determine potential benefits to the organization. (e.g., improved patient satisfaction,improved care, and lower readmission rates)Additional information can be found in the “Build a team of key players” section.Tips to engage stakeholders and secure buy-in:1. Communicate your idea for change as a conversation. “I went to the Minnesota Department of Health Stroke Conference last week and heard aspeaker from Blue Ox Hospital talk about changes they made to improve transitions of carefor stroke patients discharged from hospital to home.”2. Define the purpose for change We want to do things differently to produce better outcomes for the patient, organizationand community.3. Anticipate barriers. Barriers could include things like staffing, finances, or physical space.4. Develop a summary Here’s what our change initiative is about. We’d like to update our patient education materials so that they are more patient centeredand are consistent between the hospital, clinic and rehabilitation.7

It’s important to do because.(what’s the benefit?) Updating the patient educationmaterials and standardizing them across facilities where patients receive care will help thepatient understand what a stroke is and ways to take care of themselves.Here’s what success will look like, especially for you.Patients will know their personal riskfactors and what behavior changes need to be made. There will be less ED visits andreadmissions.Here’s what we need from you.I would like your commitment to support the use of mytime to bring a team together to work on this project, for the communication department toreview and format the materials and then to roll it out the facilities.IDEAS FOR IMPLEMENTATIONBe Innovative: This is your team’s opportunity to design a system to improve patient transitions of carethat will work in your hospital, health system and community This is the time to focus on teamwork and cooperation, and to share successes Use a “How can we do this better” approach rather than focusing on the negativeBe Creative: View this as a great opportunity to develop a better system to care for stroke patients Work together and share ideas for improvement to enhance the care of every patient It’s a chance to implement new ideas and processes Be proactive Test changes in process on a few patients to see if your “hunch” worksAdapted from Get With the Guidelines Implementation @wcm/@hcm/@gwtg/documents/downloadable/ucm 303754.pdf8

Step 2: Build Team of Key PlayersMulti-disciplinary and cross-continuum team collaboration is essential for implementing atransitions of care project. The team should meet regularly to facilitate communication andcollaboration, assess progress, and support improvement efforts in all clinical settings in which thestroke patient comes in contact.Include a Patient Perspective. It is recommended to find a way to obtain input from patients onchanges that will impact their care. This may be identified through chart review and tracking trendsor through direct patient contact/experience. If possible, include a “customer” on your projectteam to share their journey from the patient perspective.Form the Team. The initial core team should be recruited from each relevant area of care andadministration. It should include those who are familiar with policies and processes as well aspatient flow as they move from the hospital setting (ED or in-patient) to post-discharge follow-upwith primary care, neurology and others. Additional members can be identified at the first meetingthrough a work flow analysis and at subsequent meetings as identified challenges and needsemerge and a work plan is developed as described in Step 4.Consider individuals who represent the following capacities and add others not on the list.HospitalPatient, Family and/or CaregiversClinic and CommunityPatient, Family and/or CaregiversStroke CoordinatorDirector of Primary CareNeurology ProvidersPrimary Care ProvidersED Nurse/ManagerClinic ManagerStroke NavigatorHealth Care Home Coordina