Increasing Stroke Program Focus on Social Drivers of Health (SDoH)

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In 2020, we published a blog acknowledging the growing understanding of the impact of race and structural inequities on those who suffer stroke and the healthcare systems who care for them.  Over the past 4 years, we’ve witnessed a significant growth in research, publications, and presentations focused on this topic.  In 2023, The Joint Commission (TJC) added 6 elements of performance to its hospital accreditation standards to address healthcare disparities. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_disparities_july2022-6-20-2022.pdf.  The Centers for Medicare and Medicaid Services (CMS) is increasingly collecting more data to advance health equity and, in 2024, will require reporting of two mandatory measures in the Hospital Inpatient Quality Reporting Program to analyze resource use in 5 domains of SDOH. https://www.cms.gov/priorities/health-equity/minority-health/equity-programs/framework.  However, it remains unclear how this growing body of research will impact stroke programs and stroke certification standards moving forward.

While efforts to address stroke prevention and acute stroke treatment over the past 20 years resulted in reduction in mortality, studies continue to show that white individuals have appreciated the largest reduction in mortality and minority populations experience the smallest reduction.1 While efforts are underway globally to address structural inequality, studies suggest that efforts over the past decade have failed to close the gap.2  Thought leaders in the area suggest significant efforts are needed to understand the causes of inequity within and outside of healthcare so they can be addressed.3 As certified stroke centers play a key role in the stroke system of care, stroke leaders should be aware of the efforts underway to address structural inequities and determine their role in advancing this work, with or without certification standards prompting them to do so.  We’ve identified 3 key publications that address inequities at the micro, meso and macro level of stroke care delivery that may help programs focus their efforts on this space.

The American Heart/Stroke Association recently published a scientific statement on strategies to reduce racial and ethnic inequities in stroke preparedness, care, recovery and risk factor control.1 https://www.ahajournals.org/doi/10.1161/STR.0000000000000437. In addition to outlining the current state of the science, the statement provides a roadmap for health systems to address inequity through actions aimed to improve access to care, decrease barriers to medication adherence and improve care coordination and health education. The statement also describes concrete steps stroke centers and providers may take throughout the continuum of care to identify and decrease inequity.

Finally, Sur et al4 published a comprehensive review on stroke risk factor management through the lens of special groups and populations at risk for health disparities.  In addition to discussing common risk factors and addressing how different populations are impacted, the authors also address healthcare access and adherence. They call on clinicians to improve their awareness of disparities related to risk factors, cultural awareness, and evidence-based practice while calling on healthcare systems to improve access to care, implement programs that provide equitable care and target initiatives to individual populations.

Stroke program leaders would benefit from staying up to date on the evolving publications on healthcare disparities in stroke and integrate strategies to address inequities into their program plans.  Of note, after review of the impact of homelessness on inpatient resource use, CMS added three ICD-10 diagnosis codes describing homelessness (Z59.01-sheltered, Z59.02-unsheltered and Z59.00-unspecified) to the list of “CCs” (complications and co-morbidities) used in MS-DRG assignment. https://www.cms.gov/newsroom/fact-sheets/fy-2024-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective-0 (scroll down to “Social Determinants of Health Diagnosis (SDOH) Codes”)

This, and other social drivers of health coding, along with the additional information required of hospitals accredited by TJC and the measures required by CMS, may result in additional data available to stroke program leaders to plan and evaluate the stroke program and tailor initiatives to populations most affected.

References:

  1. Towfighi A, Boden-Albala B, Cruz-Flores S, et al. Strategies to Reduce Racial and Ethnic Inequities in Stroke Preparedness, Care, Recovery, and Risk Factor Control: A Scientific Statement From the American Heart Association. Stroke. 2023;54(7):e371-e388. doi:10.1161/STR.0000000000000437
  2. Hyldgård VB, Søgaard R, Valentin JB, Lange T, Damgaard D, Johnsen SP. Is the socioeconomic inequality in stroke prognosis changing over time and does quality of care play a role?. Eur Stroke J. 2023;8(1):351-360. doi:10.1177/23969873221146591
  3. Kapral MK. Kenton Award Lecture-Stroke Disparities Research: Learning From the Past, Planning for the Future. Stroke. 2023;54(2):379-385. doi:10.1161/STROKEAHA.122.039562
  4. Sur NB, Kozberg M, Desvigne-Nickens P, Silversides C, Bushnell C. Improving Stroke Risk Factor Management Focusing on Health Disparities and Knowledge Gaps. Stroke. 2024;55(1):248-258. doi:10.1161/STROKEAHA.122.040449

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.