1. Follow Up Stroke Care at Home: Beyond the Emergency Department Darren Larsen, RN, BS, CNRN, SCRN OHSU Stroke Center February 5, 2015

2. Conflict of Interest Disclosure Disclosure I do not have any financial relationship(s) to disclose.

3. Telemedicine and Stroke Oregon Health & Science University (OHSU) Telemedicine in the emergency department Telemedicine in the home and clinic

4. Patient Case OHSU Telemedicine Network

5. Stroke Prevention in the Clinic Stroke Therapy, Education and Prevention (STEP) at OHSU Nurse-led initiative begun in November 2011 Program based on protocols used for other stroke prevention trials Initiation of antihypertensives, statins, antiplatelets where indicated Education regarding diet, exercise, smoking cessation and stroke warning signs and symptoms

6. STEP Initiative for Stroke Prevention ISC 2013, Honolulu, HI Prior to discharge STEP nurse: patient medication and lifestyle education Post discharge follow up 7-10 days: Nurse call to review medication compliance and reinforce education 30 days post discharge: Seen in clinic where BP measured, medications adjusted by stroke neurologist STEP cohort compared to retrospective cohort matched based on STEP eligibility criteria for visit adherence and percentage achieving goal BPs at 30 days

7. STEP Initiative for Stroke Prevention 30 Day Visit CompletedPercentagep-value STEP Patients 25/3278% 0.0048 Matched Cohort 14/3244% Follow up adherence Blood pressures at goal ISC 2013, Honolulu, HI

8. Stroke Therapy, Education, Prevention: Telemedicine Outpatient Initiative Trial (STEP TO IT) Aims Compares those evaluated using telemedicine in the home using Cisco Jabber web based interface, that live more than 75 miles from OHSU to those seen during face to face appointments – Feasibility, blood pressure control, patient satisfaction – Secondary analyses explore other facets of stroke prevention (lipids, lifestyle measures, etc.)

9. Stroke Therapy, Education, Prevention: Telemedicine Outpatient Initiative Trial (STEP TO IT) Started enrolling 18 months ago 19 patients enrolled 6 telemedicine,12 clinic Telemedicine Setup Printed instructions Patient installs plug-in Places a test “call” Sent a link active during designated time

10. Home Telehealth Visit with Patient http://www.ohsu.edu/edcomm/flash/flash_player.php?params=1 %60/host/telemedicine/tele_monitor5.flv%60vod&width=720&h eight=405

11. Stroke Therapy, Education, Prevention: Telemedicine Outpatient Initiative Trial (STEP TO IT) Telemedicine Three complete (one by phone) Two drop-out Cost Declined further participation Telemedicine crossover due to technology Telemedicine came to clinic, did not return for 1 year visit Clinic Three complete Two drop-out Insurance Cost

12. STEP TO IT Challenges Overall – Funding – Lack of dedicated resources – Weekend coverage – Research visits required to return Telemedicine – Technology User difficulty Interface downtime Bandwidth Population – Reimbursement

13. In-home Follow Up: Beyond STEP TO IT 25 non-hospital encounters – In-home – 2 clinic locations – SNF – IPR iPad with Jabber

14. Telemedicine: Provider Perspectives

15. Telemedicine: Challenges/Limitations Testing reflexes/muscle strength Visual field testing Sensory testing Miss subtle findings Other people in the room can be distracting

16. Next Steps Continued growth in-home Stroke preventive care via telemedicine in clinic setting In place in 2 clinics, others in progress Bringing stroke care to all Oregonians

17. Thank you!