Outpatient Stroke Care: The Next Frontier?

National trends continue to predict that healthcare will move from an inpatient model to an outpatient model over the coming years.  This shift is already underway and driven by multiple factors including advancements in medications and technology, changing chronic illness demographics, payer models and investments in outpatient facilities. As this shift occurs, those in acute stroke management may be left wondering about the impact on stroke care.  Particularly when accreditation, certification and payer trends isolate various episodes in care (e.g., in-patient stroke certification, rehabilitation accreditation, value-based payments, bundled care payments, etc.). Stroke providers will be increasingly challenged to think beyond their own episode of care to address needs across the stroke care continuum. This need is underscored by evidence suggesting transitions in care are not only delayed due to limited capacity but also fraught with errors and omissions in care that can impact the safety and quality of care provided.

Reflecting on a recent patient experience where I discharged a patient with hemorrhagic stroke and multiple chronic comorbidities home with outpatient rehabilitation, the patient required additional outpatient work-up of suspected sleep apnea, improved management of hypertension and close observation after acute kidney injury.  Each of these comorbidities had the potential to contribute to another stroke event or hospitalization for other reasons. Despite these comorbidities, the hospitalization for stroke spanned only a few days and much of the care required to prevent another stroke would occur in the outpatient setting. There was little time for our care transitions team to arrange for this patient’s multiple follow-up needs before discharge.

Many organizations report new innovations in transitions of care and in stroke follow-up clinics after hospital discharge to address patient needs. Others employ stroke care navigators to help the patient and provider negotiate outpatient follow up. However, increased communication and coordination between inpatient and outpatient providers as wells as patients and caregivers will likely be required to facilitate improved care between inpatient and outpatient care.  Some promising data has emerged, including innovative transition-focused digital communication, but more study is needed to find the most cost-effective and efficient strategies to improve transitions from the inpatient setting to the outpatient setting.

While we continue to advance our acute treatments for stroke, we will be challenged to develop new, innovative models of care to improve outcomes for those who survive their stroke.

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