DRHA is Fighting Back After Brain Attack

DRHA is Fighting Back After Brain Attack

Genevieve Givens, Rebecca Engel, April Pierson, & Kali Porter
Date of original proposal:
V1: October 10, 2016
Dates of each revision.
V2: October 24, 2016
V3: November 9, 2016
V4: November 18, 2016
Date of final submission:
November 20, 2016
The University of Arizona
Clinical Systems Leadership Immersion
NURS 660

Executive Summary
Introduction
Desert Regional Healthcare Alliance (DRHA) has recognized an increased community
need for improved care management for patients post ischemic cerebrovascular accident (CVA),
otherwise known as stroke. The alarming statistics behind stroke prevalence support this need
not only locally, but nationally. Stroke is noted to be the number one disabling neurological
disease and the fourth leading cause of death in the United States (Greenberg, Aminoff, &
Simon, 2012). In 2008, $65 billion of healthcare costs were attributed to stroke, more than half of
this cost was related to hospital readmissions (Nkemdirim-Okere, Renier, & Frye, 2016). The
Fighting Back After Brain Attack (FBABA) team is proposing an evidence-based transitional
care coordination program that meets the indicators for high quality healthcare through education
geared toward symptom management and risk factor reduction. The goal of the program is to
improve post ischemic CVA outcomes, prevent secondary events, decrease readmission rates,
and in turn decrease healthcare cost to better support the health and wellness of the DRHA
community population.
Description of Care Coordination Program
Fighting Back After Brain Attack will begin with 20 patients that meet specific eligibility
criteria. The proposed care coordination program will be led by a team of four highly qualified
nurses with additional interdisciplinary consultant staff; including a nurse practitioner (NP),
pharmacist, nutritionist, and an information technology (IT) specialist. The intensive education
program is six-weeks. The participants will be both male and female, between the ages of 40 to
65 years old, and have suffered from an ischemic stroke in the past 45 days. Further eligibility
criteria includes a National Institute of Health Stroke Scale (NIHSS) score between four and
sixteen (Wong & Yeung, 2015). In addition, patients must be able to travel to the DRHA clinic
for scheduled weekly individual sessions. The program consists of visits with the provider and
customized educational sessions that continually introduce new material while reinforcing
previously covered information. In addition, the programs transitional care model and nurse-led
team facilitates the coordination of services in one location during the time patients are most
vulnerable for readmissions (Puhr & Thompson, 2015).
Delivery of Services
The transitional care coordination model will be used as the basis of the FBABA program
to support DRHAs mission and values, as well as the National Quality Strategy priorities to
improve safety, promote patient involvement, and healthy living through effective prevention and
treatment (Lamb, 2014). The program's success will be measured through hospital readmission
rates, and patient outcomes that reflect our quality indicators such as smoking cessation, lifestyle
modification, and by achieving the standards of care delineated by the current guidelines for
hypertension (HTN), diabetes (DM), and dyslipidemia (Kernan et al., 2014). Clear and accurate
data tracking is essential to ensure success of our program. FBABA will utilize quantitative and
qualitative data to highlight our success and efficiency, track progress, and institute interventions
for continuous improvement. This program will target the gaps in care through effective

education, management, and care coordination. FBABA will provide our target population with
the tools to navigate and manage their condition, optimizing their overall health.
Benefits to Target Population
The target population will receive substantial benefits from the implementation of the
FBABA program. Ischemic stroke is an abrupt life changing event. Individualized education will
empower these patients and caregivers to be active participants in the management of their
health, resulting in improved compliance, and quality of life. The rationale for this target
population is two-fold. First, the criteria will reduce potential patient attrition as these patients
have better mobility and can travel to clinic visits. Second, this program addresses patients that
would otherwise be considered too high functioning for inpatient skilled nursing or home health
services, but require assistance in navigating their condition and preventing recurrent events.
Participants will be provided with equipment and tools such as blood pressure machines,
glucometers, scales, and smartphone apps for medication management and tracking (Kennedy et
al., 2014; Wong & Yeung, 2015).
Finances for Program
As an extension of DRHA, this program will remain non-profit, but in order to begin this
revolutionary work we must first be approved for the DRHA grant. We will gain future financial
reimbursement through Medicare and Medicaid, commercial insurance, and self-pay for services
rendered. The programs commitment to efficiency and improved outcomes will directly increase
revenue through sponsor commitment, decreased hospital readmissions, and improved patient
satisfaction. In addition, FBABA anticipates obtaining grants for meeting and exceeding quality
outcomes as a pay-for-performance provider, thereby maximizing reimbursement and decreasing
financial penalties. This revenue will allow for program growth to improve access to care and
support community needs. The budget details employee cost, marketing, supplies, technology
equipment, and space renovation. The detailed developed budget is innovative and demonstrates
efficient use of resources. The program is unique because it is managed by a team of registered
nurses that will provide direct patient care and serve as managers, care coordinators, case
managers, quality and safety specialists, and patient educators. This dynamic allows for these
nurses to practice within the full extent of their scope, while ensuring financial sustainability by
eliminating unnecessary ancillary staff. Cost effectiveness is also demonstrated in the utilization
of an NP which integrates the ability for CMS approved billing for services, autonomous
treatment, medication reconciliation and symptom management (Poghosyan, Boyd, Clark, 2016).
Projected Outcomes
The FBABA program promotes healthier people while decreasing the penalties hospitals
accrue due to high readmission rates and complications from the progression of vascular disease
and debility resulting from recurrent stroke. This program aims to improve the health of our
community with focused improvement in patient outcomes. To increase the target population,
bilingual education will be available and each participants plan of care will be individualized to
their needs, and abilities. Our anticipated outcomes meet current national standards delineated
through The American Stroke Association, the American Diabetes Association, and Healthy
People 2020 optimizing the management of the attributing conditions of stroke and recurrent
stroke (Kernan et al., 2014). Our program will ensure these patients can sustain their new health
routines and education well beyond the length of our program.

Benefits to System
The need for this program was determined by a root cause analysis of higher ischemic
stroke readmission rates after discharge. The analysis identified three primary factors. The first
cause was incomplete patient knowledge of medication and the regimen that goes with each
(White et al., 2014). The second cause was poor control of comorbidities, such as HTN, DM, and
high cholesterol which attribute to higher incidents of recurrent stroke. Lastly, the third cause
was a lack of understanding of necessary lifestyle changes to ensure a successful recovery to
highest ability after stroke (Steiger & Cifu, 2016). This program, aims to prevent recurrent
stroke, while guiding patients through this health-illness transition improving health literacy,
self-efficacy, and quality of life. FBABA will benefit the DRHA system by improving outcomes,
increasing revenue, decreasing financial penalties, while providing services that meet the needs
of these at-risk patients who are often left behind in the current healthcare system.