Kentucky has one of the highest rates of stroke in the nation, and in Eastern Kentucky, the burden of cardiovascular disease is especially severe. An innovative program is improving patient outcomes and saving money in the region by providing intensive, personalized support for stroke survivors and their families.
The Kentucky Care Coordination for Community Transitions program − a partnership between the UK Center of Excellence in Rural Health (CERH) in Hazard, Appalachian Regional Healthcare (ARH), and the UK College of Health Sciences − integrates a CERH community health worker with the ARH rehabilitation team to help stroke survivors transition back to their homes and to facilitate a network of community support.
Established in 2014 with pilot funding from the UK Center for Clinical and Translational Science and ARH, the project evolved into a permanent program in 2015. Just past its two-year anniversary, the program has supported nearly 150 individuals, helping them adjust to the new realities of life after a stroke, learn about chronic disease self-management, navigate complex health care and insurance systems, monitor their rehabilitation, and connect with other survivors and caregivers.
Improving health and saving money
The program has markedly improved health and well-being for participating stroke survivors, among whom there have been zero 30-day hospital readmissions and only one emergency department visit (which wasn’t stroke related). This is compared to 19 percent and 8 percent, respectively, of the matched control group of stroke survivors who chose not to join the program. The result is not only better health and quality of life for survivors and caregivers, but also a cost savings of more than $1.4 million over two years to the local healthcare system.
“We’re keeping people healthier and saving a phenomenal amount of money for the health care system,” said Patrick Kitzman, PhD, founding director of the program and professor of physical therapy in the UK College of Health Sciences. “But we also concentrate very much on the caregiver and family − we always look at the whole unit with our follow-up education and support.”
In 2016 alone, the program supported 70 individuals, including 512 encounters between the community health worker and participants and more than 1,000 provided services. Half of participants needed assistance obtaining durable medical equipment, 71 percent needed assistance obtaining essential medications, and 35 percent needed assistance obtaining health insurance.
A critical element of the program’s success is the integration of the community health worker, Keisha Hudson, with the stroke rehabilitation team at ARH. Hudson, who is from the local community, participates in the discharge planning for participating stroke patients so that she can establish a relationship with them and their families while they’re still in the hospital and get a head start on arranging for anything they might need when they get home − shower chairs, wheelchair ramps, medical equipment, etc.
Hudson then visits patients at their home within a week of discharge and provides weekly face-to-face meetings or phone follow-up calls which tapers to bi-weekly or monthly check-ins as patients improve. Some patients, however, have stayed with the program since its beginning.
As she works with patients and families, Hudson provides health education and tracks compliance with medical visits and medication; when she notices that a patient has missed an appointment or medication, she figures out why. Sometimes the problem can be as simple as the patient lacking transportation, in which case Hudson can help them make arrangements to get to the clinic or pharmacy.
Such attention and regular communication allows Hudson to develop a personal relationship with patients and their families to the extent that she can often sense when something is “off” and intervene before a serious problem develops. While none of the patients in the transition program have been readmitted to the hospital for stroke complications within 30 days of discharge, Hudson’s attentive care has led to life-saving interventions related to patients’ other health issues; nearly 60 percent of participants have five or more co-morbid health conditions. Once, while speaking with a patient over the phone, Hudson recognized that the woman’s breathing sounded especially labored, and she told the patient to go to the hospital immediately. It turned out the woman had a dangerous level of fluid on her lungs and needed urgent treatment. While making a routine visit to check on a different patient, Hudson arrived to find them in a diabetic coma. With yet another patient, she caught an infected surgical site that required immediate attention.
Connecting with the community
Hudson also hosts a monthly stroke survivor and caregiver support group. It meets at the hospital, which allows currently hospitalized stroke survivors or their caregivers to come downstairs from the care unit and connect with the group before they go home.
“The program has evolved in the community because we’ve built trust as people hear about us through word of mouth. Some patients and caregivers have become really big advocates for us. One of the patients we’ve worked with for a while has had people in his community who’ve had strokes and he himself has referred them to us. We’ve proven to our community that we’re here to help and we’re here to stay and when we say we’re going to do something, we do it − that’s helped a lot,” Hudson said.