Patients admitted to the ED for stroke and other neurological conditions have better functional outcomes and quality of life when enrolled into a nurse-led post-discharge service, a WA study shows.
The intervention also brought substantial cost savings, with patients who opted into the service reporting fewer ED and hospital readmissions saving the hospital an estimated A$101,639 per annum or A$275 per patient annually, compared to standard post discharge care.
Amid heavy demand for Perth hospital neurology services the team behind the program – Neurological Change and Development Nurse at the Neurological Council of Western Australia, Dr Judith Pugh and colleagues from the Fiona Stanley Hospital – said high 28-day readmission rates prompted their investigation into alternative routes of post discharge care.
Writing in Health and Social Care, the group revealed that unpublished data between 2014–2018 showed 62% of the hospital’s adult neurology patients were readmitted within 28 days of discharge.
These were patients with a primary diagnosis of stroke, epilepsy, migraine/headache or functional neurological disorders (FND) and approximately half were readmitted for non- neurological reasons. Some, like falls, pneumonia, and urinary tract infections, were potentially preventable said investigators – and potentially responsive to timely, community-based nursing intervention they added.
Recognising the role of community neurology nurses (CNN) Dr Pugh and colleagues looked at integrating the specialist nurses into the unit’s multidisciplinary teams at the discharge planning stage.
Supporting discharge home the community neurology nurse helped with coordination of care, neurological nursing assessment and home based care including home visits, Telehealth, and maintaining communication post discharge through text messages and email.
“The [community neurology nurse] provides a bridge between hospital inpatient care and community care seeding a therapeutic relationship with patients before their discharge,” investigators said of the important role.
High risk for readmissions
The service, called Neurocare, was offered to 177 acute care adult patients admitted to the neurology ward of a WA hospital with a diagnosis of stroke, epilepsy, migraine/headache or FND and discharged home.
Of the patients offered the service, identified by clinicians for being at high risk for readmission, 81 patients enrolled into Neurocare. Just under half of the patients who turned down the service cited managing well with informal supports and other services.
A retrospective group of 740 patients who received the previous model of care made up the comparator group.
Alongside nursing clinical assessment and arranging referrals, the CNN role was far-reaching: undertaking comprehensive needs/wellness assessments including assessing and establishing support systems, and monitoring patient health and functional status, which enabled early identification of risk for clinical deterioration .
Additionally, the community neurology nurse provided patient education to improve their knowledge about their medications, neurological and other health conditions, symptom management and lifestyle modifications.
According to investigators most Neurocare patients had mild to moderate levels of disability at discharge, yet many had complex ongoing disease-specific needs and needs relating to their multiple chronic health conditions.
The three top-ranking domains for clinically important impairment were: Anxiety (n = 19; 43.2%), Sleep Disturbance (n = 17; 37.8%) and Ability to Participate in Social Roles and Activities (n = 18; 40.9%).
At one-month follow-up improvements were statistically significant for daily living activities (p = .0001), moving around, including for fall and near falls (p = .001), thinking and remembering (p = .018) and sleep and endurance (p = .002) compared to baseline.
Meanwhile fewer cases of new pain or pain interfering with activities were reported with more patients recording improvements in their ability to carry out leisure, social or work actives compared to the standard post discharge care group.
In the 3-month post discharge period, nurse contact (telephone and/or home visits) totalled 60– 445 min (M = 170.0; SD = 70.8).
Improvement in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), cognitive function and social role function was observed across the intervention group compared to standard care as well as less need for equipment and services compared to standard care at follow up.
Patients also reported improvements in most HRQOL domains after receiving Neurocare. The finding is particularly ‘encouraging’ say investigators given the older age of the Neurocare cohort and accompanying high rates of comorbidities that typically leaves the patient subgroup prone to declining functional status, reduced QOL and increased risk for readmission and poor outcomes.
“Incorporating older patients’ health goals, preferences, priorities and capabilities, as the Neurocare model does, is more likely to reduce their burden of health-care and avoid potentially unwanted care compared with patients receiving usual care, investigators maintain.
The study was published in Health and Social Care in the Community