Friday, July 1, 2011

Care redesign teams move forward with recommendations

Stroke strategy: From left, Joyce McIntyre, RN, clinical nurse specialist for Emergency Services; Aneesh Singhal, MD, a stroke neurologist and the Department of Neurology quality chair; and Schwamm at one of the team’s meetings

Teams of experts from the MGH and other Partners affiliates are focusing on improving care in certain disease areas, and an initial group of five teams has developed recommendations for colon cancer; coronary disease, specifically acute myocardial infarction and coronary artery bypass graft surgery; diabetes; primary care; and stroke. In May, the recommendations were reviewed and approved by leadership, and teams now are moving forward with implementation. MGH Hotline is publishing a series of articles detailing the efforts of several of these teams.

Despite increased prevention efforts, nearly 800,000 individuals in the United States will have a stroke this year. When someone has a stroke, it is crucial for that person to receive highly coordinated care – from the time he or she first arrives at the hospital, when the need for administration of a clot-busting drug immediately must be determined – to the weeks or months of rehabilitation that may be required before going home.

One of the many teams involved in the care redesign process is focusing on ways to improve outcomes and streamline care for adult patients who have had a stroke or transient ischemic attack (TIA), a warning sign that indicates a stroke may occur. The multidisciplinary team comprises physicians, nurses, physical therapists, administrators and other staff and is led by Lee Schwamm, MD, director of the MGH Acute Stroke Service and vice chairman of the MGH Department of Neurology.

“What all stroke and TIA patients have in common is that they require complex medical care,” says Schwamm. “Unfortunately, this care is sometimes fragmented or less efficient than it could be. Too often, for example, TIA patients are admitted to the hospital and remain there for days while testing is performed, when it could be done more safely and effectively in an outpatient setting. For stroke patients, better coordination among providers and increased guidance after discharge are needed.”

With challenges like these in mind, the team has closely examined care provided to this patient population and identified opportunities for improvement. Based on its findings, the team’s recommendations are:

  • Create a “clinic of the future” to provide a seamless, one-stop shop for patients suspected of having a TIA;
  • Establish innovative care environments (such as a stroke mini-step down unit) to help avoid readmission and reduce intensive care unit stays;
  • Use uniform and evidence-based protocols for initial and follow-up testing and treatment; • Use a “discharge-readiness” checklist to minimize avoidable delays;
  • Establish checklist-driven guidelines for assessing rehabilitation needs and determining the appropriate discharge destination;
  • Establish alternative rehabilitation options to more effectively align resources to patients’ needs; and
  • Engage patients more effectively in achieving their longterm care goals.

Working in collaboration with caregivers at the MGH and other Partners hospitals, the TIA clinic of the future and the discharge-readiness checklist will be the first measures piloted by Oct. 1.

“I am very excited to partner with the stroke team during the implementation phase,” says Suzanne Algeri, RN, nurse manager of White 12 Neurosciences, who will help lead implementation at the MGH on one of several floors. “Their recommendations for care redesign continue to build upon our commitment to provide exceptional care to our patients.”

To measure the effectiveness of their recommendations, the stroke team will monitor each patient’s treatment and outcome, measuring how well the patient is functioning at 90 days after the event as well as the number of days the patient spends at home in the first three months. At the same time, the team will track costs to the patient, the MGH and Partners to ensure resources are being used responsibly. In addition, the team will survey the response of the patient to the new approaches.

“I believe our recommendations will improve the quality of the care we provide by making it more predictable, more routine and more consistent whenever it can be and by making it highly individualized where it needs to be,” says Schwamm.

In addition to the groups mentioned above, five new teams have been launched in vaginal delivery, total joint replacement, endovascular procedures, lung cancer and transplantation. For more information about the Partners Strategic Initiative and the other care redesign teams, access

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