December 2018, Volume XXXII, No 9
Stroke and telehealth
Improving access and outcomes
ccess to specialty care in rural areas is often limited by distance and accessibility. Rural Minnesotans and specialty providers are well aware of this challenge. Residing in or visiting the remote areas of Minnesota can mean long drives to medical facilities and, in certain cases, additional time needed for emergency medical transportation, evaluation, and initial treatment, resulting in vastly varying outcomes.
In rural Long Prairie, Minnesota, an 80-year-old resident experienced this firsthand. Waking up with tingling in her left arm, numbness in her left leg, and the inability to eat her breakfast, she knew something wasn’t right. Looking in the mirror, the facial droop that was reflected back wasn’t good.
What she had feared was confirmed quickly at CentraCare Health–Long Prairie, where a CentraCare Health telestroke provider located in St. Cloud solidified the stroke diagnosis via telehealth. In this case, the online technology was utilized to provide care remotely, offering instant access to critical care and an off-site stroke specialist. A telestroke specialist was able to review scans and suggest further care at the moment of the stroke presentation. For many patients that otherwise would not have the means to access early specialty care, telehealth technology speeds treatment decisions, thereby improving patient outcomes.
Weeks later, after treatment and extensive inpatient rehabilitation at the CentraCare Health– St. Cloud Hospital, the patient was able to return home. This wasn’t something she was expecting based on her initial reflection in the mirror, but thanks to early evaluation, treatment, and transportation, what could have been worsened by delay was avoided. Further post-stroke recovery and rehabilitation continued at her rural Long Prairie home health care facility via the Telestroke/Vascular Neurology Clinic.
More than 11,000 square miles and almost 500,000 people now have access to telehealth services.
Online access to care
The Telestroke/Vascular Neurology Clinic was established to improve access to care and health outcomes among rural Minnesota patients recovering from stroke or transient ischemic attack (TIA). It provides nurse care coordination services by a trained registered nurse patient navigator, who works directly with patients to eliminate barriers to care and to guide rural patients through the systems of care. The program also coordinates follow-up appointments with a stroke specialist from the St. Cloud Hospital Stroke Center via telemedicine at consortium hospitals and clinics. This enables patients to stay in their home areas and visit their primary care providers in local offices as they always have, but visits with specialists, such as stroke neurologists, are conducted via the telehealth equipment.
Recovery plans are also developed for each patient, with the patient navigator ensuring that discharge instructions, medications, and follow-up appointment schedules are followed, while also assisting with resources to obtain medications, equipment, transportation, and anything else they may need. If gaps in care are identified, the nurse navigator works with the stroke provider and the patient’s primary care provider. Providers that are in the CentraCare telestroke network can refer patients to the telestroke/vascular clinic for follow-up.
More than 11,000 square miles and almost 500,000 people now have access to CentraCare telestroke services.
(Asterisks indicate sites that are not operational for post-stroke care yet, but will be in the next three years due to further grant funding.)
In 2015, a needs assessment identified that targeted counties in the central Minnesota area had almost 6 percent more senior citizens residing in them than the state average. These senior citizens are at greater risk for stroke or TIA. Several gaps in care were identified: difficulties with transportation for follow-up care at the stroke clinic in St. Cloud; lack of education on post-stroke care; and the need for navigation to therapies and medicine post-stroke. These gaps in care increased the risk of repeat strokes and hospital readmissions.
In response to this need, CentraCare Health–Long Prairie was awarded a Health Resources and Services Administration (HRSA) Rural Health Care Services Outreach grant in 2016.
Most (87 percent) felt that the quality of care they received was as good as a face-to-face visit.
Table 1. Thirty-day readmission rates for inpatient care and telestroke participants
Table 2. Ferrans and Powers Quality of Life Index Stroke Version–III.
Table 3. Modified Rankin Scale.
Muhammad Fareed K. Suri, MBBS, is the stroke medical director at St. Cloud Hospital. He is board-certified in vascular neurology and neurocriticial care and is a fellowship-trained interventional neurologist. He received his medical education through Army Medical College/Quaid-e-Azam University and completed an internship and residency at the University Hospitals of Cleveland, an interventional neurology fellowship at the University of Minnesota–Department of Vascular Neurology, and a vascular neurology fellowhip at the UMDNJ-University Hospital. His services include: interventional neurology, stroke care, neurocritical care, and vascular neurology.