December 2018, Volume XXXII, No 9

special focus: rural Health

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.

One patient’s experience

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.

Telestroke sites

More than 11,000 square miles and almost 500,000 people now have access to CentraCare telestroke services.

  • Telestroke facilities include:
  • Aitkin–Riverwood Health*
  • Alexandria–Alomere Health *
  • Appleton–Appleton Area Health Services *
  • Benson–Swift County Hospital
  • Glenwood–Glacial Ridge Hospital
  • Hutchinson–Hutchinson Health *
  • Little Falls–CHI-St. Gabriel’s Health *
  • Long Prairie–CentraCare Health
  • Madison Hospital*
  • Melrose–CentraCare Health
  • Monticello–CentraCare Health *
  • Olivia–Renville County Hospital *
  • Paynesville–CentraCare Health
  • Redwood Falls–Redwood Area Hospital*
  • Sauk Centre–CentraCare Health
  • Staples–Lakewood Health System
  • St. Cloud Hospital–CentraCare Health
  • Wadena–Tri-County Health Care
  • Willmar–Carris Health

(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.)

Background

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.

Outcomes

This instant access to stroke care and coordinated after-care services—which often surpasses resources available in rural areas—has improved readmission rates, patient experiences, post-stroke quality of life, and degrees of post-stroke disability:

Readmission rates. From program initiation on June 1, 2015, to program close on April 30, 2018, a total of 132 patients were enrolled in the program. Among the 132 enrolled, 26 percent (n=34) had a TIA and 74 percent (n=98) had a stroke. Overall among the enrollees, there were 24 readmissions, nine within 30 days of discharge. This rate is lower than CentraCare’s all-cause 30-day readmission rate as of March 31, 2018. See Table 1.

Patient experience survey. Twenty-five patients, all of whom had a telehealth visit, completed the patient experience survey. Questions and responses:

  • I feel the quality of care I received today through the video conference is as good as a face-to-face visit: 87 percent.
  • I would rather drive farther for a face-to-face appointment than have a visit again through a teleconference: 8 percent.
  • I felt comfortable talking freely with the stroke doctor or nurse via the video conference equipment: 100 percent.
  • I was comfortable meeting with the stroke doctor or nurse via teleconference: 96 percent.
  • I could clearly see and hear the stroke doctor or nurse on the video conference: 83 percent.

Patient quality of life and degree of disability. The patient navigator administered the Ferrans and Powers Quality of Life Index Stroke Version–III to patients via mail at enrollment. The index was re-administered at six months post-program enrollment via mail. The index is scored on a scale of 0–30, with 30 being good quality of life. Since program initiation, 35 patients completed the QOL at baseline and at six months. The mean change across these patients was 5.40. A paired sample t-test comparing the means at baseline and at 6 months was significant (p≤.01). See Table 2.

The patient navigator also administered the modified Rankin Scale (mRS) to patients during the first visit. The scale was re-administered at three and six months via phone. The index is scored on a scale of 0–6, with 0 being no symptoms and 6 being clinically dead. Since program initiation, 81 patients have completed the mRS at baseline and at six months. The mean change from baseline to six months was -.59, which is statistically significant (p≤.01). See Table 3.

Evaluation findings suggest that patients view the Telestroke/Vascular Neurology Clinic positively, and program data demonstrates that patients enrolled and assessed in the clinic experienced statistically significant improvements in both quality of life and degree of disability.

Out of 25 patients surveyed, most (87 percent) felt that the quality of care they received was as good as a face-to-face visit.

The SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis confirmed that key program strengths include continued optimism among program partners that the Telestroke/Vascular Neurology Clinic can improve access to care and patient health outcomes. The SWOT analysis also identified several opportunities for future expansion of teleneurology and telemedicine.

The Telestroke/Vascular Neurology Clinic can serve as both a model for telemedicine in other rural areas and for other disease conditions. Evaluation findings demonstrate the importance of assisting patients in barriers common to rural areas that would otherwise impede them from receiving proper care.

Summary

The Telestroke/Vascular Neurology Clinic program evaluation demonstrated that:

  • Patients report a high degree of satisfaction and positivity with their telehealth experience.
  • Patients enrolled and assessed in the Telestroke/Vascular Neurology Clinic experienced statistically significant improvements in both quality of life and degree of disability.
  • Patients enrolled in the program demonstrated a lower 30-day all-cause readmission rate compared to the CentraCare Health rate.
  • There are numerous opportunities to expand and sustain program components, many of which have been identified and incorporated into new models and funding streams at CentraCare Health. These include expansion of the Telestroke/Vascular Neurology Clinic to additional sites throughout rural Minnesota.

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. 

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.

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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.