This document discusses factors that contribute to readmissions of stroke patients and interventions to reduce readmissions. It notes that readmissions account for 20.5% of hospital admissions and reviews reasons for readmissions like medication issues, lack of follow-up care, and unhealthy lifestyles. The document outlines programs like TRACS, COMPASS and MISTT that provide post-discharge support through nurse coaching, medication management support and lifestyle counseling to reduce readmissions.

1. Reducing Stroke Readmissions in Acute Care Setting
Contents
Introduction: 2
Objective of the study: 3
Readmission Factors: 3
Statins: 3
Long term care: 4
Demographics: 4
Personal Reflections: 4
Events: 4
Empirical Evidence: 6
Interventions for discharged patients: 6
TRACS: 7
COMPASS: 7
MISTT: 8
Clinical requirement: 8
Timeline: 8
Collaboration with the preceptor: 8
Proposed evaluative criteria: 9
Evaluative criteria discussed: 9
Conclusion: 9

2. Bibliography 10
Introduction:
Stroke refers to a cardiovascular disease which has been one of
the leading reasons for deaths and long term disability. A stroke
is an abrupt onset of a neurological deficit led by a vascular
rupture or blockage that reduces the blood flow to brain.
Subsequently, causing death to the tissue in the brain region if
interruption of the blood flow persists. The indications of stroke
vary, but may include the loss of function to one side of the
body, the inability to speak or talk, and reduced vision or severe
headache (Poston, 2018).
Issue: Discovery Research
Over time, the financial penalties on readmissions to the
hospital have been taking place, which is promoting hospitals to
take measures to reduce the instance of readmissions. A variety
of interventions are taking place on different levels to ensure
that pre and post discharge care is in place to avoid
readmissions. The efficacy of interventions is dependent on the
variety of components. Single component interventions are least
effective and tend to have no effect on readmissions to the
hospitals. Patients that are discharged to post-acute care
accommodations are subjected to multi-component interventions
and readmissions have dropped drastically. These interventions
work through communication, advanced planning of care, and
training to tackle simple medical issues that might cause
readmissions. The availability of risk stratification methods
have made it easier for the hospitals to give more care and
attention to the patients that are more likely to get readmitted.
Home based services are provided to ensure proper medical care
for the patients.
This capstone project attempts to discuss the factors causing the
readmissions of stroke patients to the hospitals. The past 20

3. years have proven to be important in acute and inpatient stroke
care however, quality of post-acute care varies specially for the
patients that are discharged to home. (Condon, Lycan, &
Duncan, 2016). Different reasons for stroke readmissions are to
be examined in this capstone project. Expected Outcomes:
Discovery Research
This project aims to take into account the reasons of stroke and
readmissions after being treated for stroke. Stroke is the second
primary reason of readmissions in the hospital. Major
readmissions comprise of elderly people. 20-70% people who
survive stroke are readmitted in the first year of their treatment
(Bravata, Ho, Meehan, & Brass, 2006). Poor health conditions
and high treatment costs both account for the largest reasons for
recurrent strokes. Cardiac arrest is also common after
strokes.Literature: Evidence Summary-Knowledge Generating
Stage
Prevention of ischemic strokes can be achieved if the reasons
for readmissions are studied and considered. In 2013,
Nationwide Readmission Database provided statistics regarding
strokes. It showed that 12.1% patients having stroke were
readmitted in a time period of 30 days of discharge of which
89.6% were not planned and rest were foreseen. Annual cost of
Stroke care in United States of America is $34 billion.Statins:
Statins are the drugs prescribed by health care professional to
reduce or control cholesterol levels. Studies show that patients
using statins are less likely to be readmitted to the hospitals as
compared to those not taking statins. Another important factor
is age. People less than 80 years of age are less likely to be
admitted to the hospital and those above the age of 80 are more
likely to be readmitted.
Methodology for implementation of the Project
Studies reveal that one third of the patients of stroke require
long term care after they are discharged. Certain patient
characteristics such as lower comorbidity scores or higher level
of participation in nursing homes after discharge from hospital

4. lower the odds of readmissions.
Findings from what you’ve implemented
Patients from urban areas are more health conscious and have
more awareness and information regarding post discharge care.
Therefore, urban area patients are less likely to get admitted to
the hospital after being discharged.
Evaluation- Process and Outcome Evaluation. Impact of EBP
Summary: Practice IntegrationPersonal Reflections:
Different health conditions are prevailing that result in
readmission to the hospital. However, it has been observed that
stroke accounts for 20.5% of readmissions in hospital.
Therefore, this has been selected for capstone project. Western
countries are most vulnerable to this situation because of
lifestyle conditions. Smoking, drinking, diabetes and
hypertension are contributing factors. Lack of healthy lifestyle
and exercise also play their part in deteriorating health
conditions (Kripalani & Theobald, 2014). The need of the hour
is to educate nurses so as to create awareness for adoption of a
better life style. Also, nurses have to have awareness to take
better steps to ensure proper health conditions before
discharging stroke patients. Analysis: Translation into
Guidelines
Various activities and steps are formulated to educate nurses to
reduce readmissions to the hospitals. Community awareness
programs are also on the agenda to adopt healthy lifestyle and
incorporate exercise in daily routine. First of all, I plan to chalk
out a proposal so as to identify the areas where improvements
are needed. The cardiac head of the facility should be included
in the program. Stroke alerts are important step that needs to be
taken. The researcher plans to take rounds to the inpatient rehab
physician and outdoor units. This will help collect data to feed
the awareness program. After the collection of data, information
regarding health care will be provided to the nurses. Family
information of the patient is also required to have a better look
at the events. Taking all information into account, nurses will

5. have a better understanding of the reasons leading to
readmissions. They can then use this information to make sure
those readmissions decreases as much as possible. PowerPoint
presentations are on the agenda as creating awareness visually
is better and efficient. Also, families and peers of the patients
are also to be included in the program because they are the ones
who will be taking care of the patients. Extra fats and
cholesterol are to be discouraged and dietary intake, fruits and
vegetables is to be promoted.
60% of the stroke patients require care in a proper setting that
includes nursing centers, rehab centers and home health. This
shows that healthcare transitions to a better facility can be
achieved by identifying and documenting issues and
implementing strategies to address them. The transition plan
also needs to be effectively delivered to the nurses to have a
beneficial outcome.
The research plans to get an outcome in the form of less
readmissions and awareness among the nurses. Reoccurrences of
strokes would decrease as people move towards a better and
healthy lifestyle. Evidence from the research shows that
acceptance of a healthy lifestyle and giving up smoking makes
people less prone to another stroke. This has led to a decrease in
readmission rates. Pre discharge and post discharge care and use
of proper medications would decrease the chances of stroke
(Kristen, 2018).
Research encompassing readmissions due to stroke is not very
extensive. Most of the studies do not even include stroke
patients. Transitional care model formulated for other diseases
when applied to stroke showed promising results. It was
surprising as they were not even formulated for the stroke
patients. However, the researchers are still looking and
formulating other models as multi models helps in cost cutting,
provision of patient-centered care and lesser readmissions.
Various programs have been initiated in other states, such as
TRACS (Transition Coaching for Stroke), COMPASS
(Comprehensive Post-Acute Stroke Services) and MISTT

6. (Michigan Stroke Transitions Trial) etc. (Kristen, 2018).
It is quite evident from the research that patient care after
discharge is imperative to control readmissions. Journals have
also focused studies on the importance of ambulatory care
practice in promoting efficient evolutions post-acute care.
A study conducted by Hansen and associates shows that
readmission to the hospital can be reduced using various
interventions. The authors suggested that intervention
constituents should be classified. Pre discharge interventions
include understanding of medication, scheduled appointments
before discharge, educating the patients and planned discharge.
Post discharge intervention comprises of home visits, hotline
for patients information, PCP communication, well-timed follow
ups and telephone follow ups by the hospital. Bridging
interventions are to be promoted too, which encompasses
discharge instructions focused on patients and transition
coaches. However, the study revealed that adopting only one
form of intervention does not ensure less readmission.
Coleman developed a CTI (Care Transitions Intervention) that
encompasses a training nurse that helps patients to take better
care of them. It comprises of four key points; self-managing
medicines, recording health essentials, follow-ups and
awareness of red flags. This helped in reduction of 30 day and
90 day readmissions and was applicable globally (Coleman,
2009).
TRACS provides one of the most encouraging frameworks to
provide additional clinical trial at the time of discharge of
stroke patients. It provides immediate coaching sessions
through a nurse to the stroke patients that are discharged
recently. The participants of the program receive follow up
phone calls that reviews medications and assess problems that
might arise. Each participant patients gets a call regarding their
appointments with the doctor. This was quite successful as the
medication persistence reached 80.3%. Also, patients getting
follow up calls regarding checkups are more likely to go for
checkup and this resulted in 48% decrease in readmission rate.

7. This model comprises of an extensive trial encompassing 41
hospital sites and 6000 participants. The foundation of this
model lies in TRACS. But, it has more extensions so as to
discuss the problem comprehensively. The main points of this
model include follow up calls after 2, 30 and 60 days after
being discharged. Provision of transport facilities to
appointments is also an important part of this program. A web
based application named as COMPASS-CP is formulated to
provide all the basic and necessary information. This
application also provides referrals and generates a customized
plan form individuals.
MISTT addresses health related and psychosocial challenges
that are faced by survivors of stroke and their caretakers. This
emphasizes on patient activities and quality of life and take
measures to improve it. This program ensures that health
workers plan a visit to the patient’s house within a week of
discharge and another visit after 30 days of discharge and
follow up phone calls every week. The eventual aim is to
promote the engagement of patients and caregivers in decision
making and achieving good health via incorporating proper and
healthy lifestyle.Clinical requirement:
Proper follow up of patients is required. Also, they are required
to take their medications timely and adopt a healthy life style.
The nurses need to provide all the required information
regarding health care and patients are to give up bad eating and
lifestyle habits. Timeline:
It is expected that the results would be seen after a time period
of 14 weeks. One month of rigorous training would be provided
and then one month would be required to create awareness.
Collaboration with the preceptor:
The preceptor which is the head of nurses would keep on
providing relevant data to give necessary insight. Also, they
would be a channel through which proper communication would
take place. Also, they would make sure that the nurses are
sticking to the given protocol.Proposed evaluative criteria:
Evaluation criteria refer to the outcomes of the project. The

8. researcher would study and evaluate the effectiveness of the
project by observing the number of readmissions. Lesser the
readmissions due to stroke, greater would be the efficiency of
the project.Evaluative criteria discussed:
The nurses would keep an eye on the patients and provide
information to them regarding post-acute health care. Also, they
would make sure that the families and relatives of the patient
conform to the prescribed medications and lifestyle.
Conclusion:
Medication issues are the most common ones that lead to
seeking emergency prematurely. Need for education and
support is also required to cater this issue. According to a
research the cost of for uninsured patients is $52,000 annually
and the cost for readmission is $11,200. Readmissions after
ischemic strokes is of crucial importance and is quite complex
(Leonhardt, Burgen, & Wolfe, 2016). Identification of key
issues needs to be done which is why this study is being
conducted. The scientific literature reveals that individual
efforts are less likely to cater this problem, however, some steps
can be taken such as promoting multiple components that deals
with both inpatient and outpatient care. Evidence of relationship
between number of components and effectiveness of a program
is also observed which calls for more robust interventions.
There is a window of opportunity among the acute care of
stroke and readmissions which can be helpful to reduce the post
stroke morbidity burden.
Bibliography
Bravata, D., Ho, S., Meehan, T., & Brass, L. &. (2006).
Readmission and Death After Hospitalization for Acute
Ischemic Stroke.
Coleman, E. A. (2009). Rehospitalizations among patients in the
Medicare fee for service program. 18-28.
Condon, C., Lycan, S., & Duncan, P. &. (2016). Reducing
Readmissions After Stroke With a Structured.
Kripalani, S., & Theobald, C. &. (2014). Reducing Hospital
Readmission: Current Strategies and Future Directions. Annual

9. Review of Medicine .
Kristen, M. (2018, Decemeber 10). Reducing readmissions in
stroke patients. Retrieved March 18, 2020, from American
Nurse: https://www.myamericannurse.com/reducing-
readmissions-in-stroke-patients/
Leonhardt, A., Burgen, D., & Wolfe, J. &. (2016). Development
of a Collaborative Transition Coaching Program for Reduction
of Post-stroke Hospitalizations. AHA.
Poston, M. K. (2018). Reducing readmissions in stroke patients
. American Nurse Today.