A Common Mistake in Resourcing Comprehensive Stroke Centers

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One of the biggest mistakes made by leadership at Comprehensive Stroke Centers (CSCs) is running the coordination and operations of the program on a Primary Stroke Center (PSC) model.  This is also true, albeit to a somewhat lesser degree, in Thrombectomy-capable or PSC+ Stroke Centers.

Picture this: A program achieves PSC certification with a medical director and stroke coordinator leading the charge.  The work is challenging but manageable, and the stroke committee meets once monthly to review data and any operational issues that must be addressed. The program grows over time in-patient volume and complexity, physician providers are added to offer additional services and the stroke program leadership adds a data analyst.  But most of the work holding the stroke program together (e.g. data collection and quality improvement (QI) initiatives, staff education, process management) continues to be owned by the coordinator and medical director. The program then launches a bid to become CSC certified.

CSC Certified – Creating A Sustainable Comprehensive Stroke Center

This is the moment of compression: the work of managing the program must be redistributed in order to create a sustainable CSC.  This isn’t just a problem plaguing programs looking to become CSC certified. Many existing CSC are struggling with sustainability and recertification because they didn’t navigate this transition well. There are several characteristics of organizations that have created a sustainable CSC model:

  • Physician leadership – While a PSC can thrive with one medical director, a CSC needs strong physician leadership from multiple areas, including vascular neurology, neurosurgery, neuroradiology, neurocritical care and the emergency department. One could argue the need to also have physician champions for the stroke program in vascular surgery and outpatient clinics as well. Whether this takes the form of several program medical directors or some other way to recognize their leadership, a strong alliance is necessary to distribute workload and coordinate services.
  • Data management – CSCs are required to manage many more data points and QI initiatives than a PSC, and this work flows best when the CSC is supported by the organization’s PI or Quality Department. Often, multiple sub-committees or task forces are needed to manage QI initiatives and report up to program leadership. And individual units may need to take on the responsibility of managing its own QI data and reporting back to program leadership. Units must also accept the responsibility of implementing initiatives and disseminating the ongoing results of QI work to their staff. The CSC stroke coordinator and medical directors should be overseeing high-level QI initiatives, not immersed in data collection and results dissemination.
  • Education – While the Stroke Coordinator at a PSC may be responsible for nursing and patient education, this model is not sustainable at a CSC. Similar to data management, CSCs function best when they shift the work of nursing education back to the unit leadership. While program leadership may help to guide the topics needed for education, individual units should work to conduct a needs assessment, own the content and educate their staff on stroke care.

Those programs that rearrange workflow and accountabilities are best prepared for TSC and CSC certification, recertification and/or building a sustainable program.

Are Medicare Bundled Payments for Stroke Coming to Your Hospital?

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It’s likely that the majority of your stroke patients are covered by Medicare so you should be aware that, in 2019, hospitals are going to be offered an advanced Medicare “bundled” payment model for stroke.

Medicare bundled payments represent a single payment (usually to the hospital) for services provided during an episode of care for a defined period of time. In this payment model for stroke, Medicare pays the hospital one “bundled” payment which includes payment for hospital, physician and rehabilitation services. It is up to the hospital to pay physicians and rehabilitation facilities for their services.

Medicare uses their claims database to find areas where there is unexplained variation in patient level cost across hospitals. They identify types of care and more specifically, episodes of care where they feel there is opportunity, given the right incentives, to reduce variation, reduce cost and improve quality of care.

While stroke has been one of 48 episodes of care offered to hospitals for several years, few hospitals have chosen stroke for bundled payments. But that may change.

bundled payments for care improvementBundled Payments for Care Improvement

Stroke represents a hyper-acute stage of hospital care followed by a transition to rehabilitation or skilled nursing home and, with more tightly coordinated care in certified stroke centers, stroke may be viewed as an ideal episode of care for bundled payments.

With prompt diagnosis and treatment, adoption of evidenced-base protocols, more longitudinal coordination of care and improved patient outcomes, more hospitals may be interested in the financial incentives offered in the new advanced bundled payment model for stroke.

If you work with your revenue management (or hospital reimbursement) team, with some analysis of the cost of different types of stroke in your hospital, you may be the one to advocate for (or perhaps, against) bundled payments for stroke for your hospital.

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References:

Washington Health Alliance. Hospital sticker shock: A report on hospital price variation in Washington state. https://wahealthalliance.org/wp-content/uploads/2014/10/hospital-sticker-shock-report-chart-pack.pdf.

Luengo-Fernandez R, Gray AM, Rothwell PM. Costs of stroke using patient-level data: a critical review of the literature. Stroke. 2009;40: e18–e23. doi: 10.1161/STROKEAHA.108.529776.

Miller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer, Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health Aff (Millwood). 2011;30:2107–2115. doi: 10.1377/hlthaff.2011.0783.

Newhouse JP, Garber A, Graham RP. Interim Report of the Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Health Care: Preliminary Committee Observations. Washington, DC: The National Academies Press; 2013.