Stroke Protocols Ensure Efficient Patient Intake, Diagnosis, Treatment Utilize Data Metrics to Continually Evaluate Protocol Efficiency with Stroke Response Team Sample Stroke Care Pathway EMS pre-alert sent to ED and stroke response team On-call neurologist makes diagnosis and outlines treatment plan Neurointerventional treatment conducted (if applicable) Patient immediately evaluated for stroke with blood tests and relevant diagnostic imaging IV-tPA administered (if applicable), patient monitored for improvement Pre-discharge care and patient education provided Advisory Board’s Tips for Implementation 1 Streamline Staff Involvement Action Steps Outline specific needs from clinicians and administrators at each step throughout care pathway Only utilize staff when necessary to maximize physician and program capacity 2 Clearly Communicate Steps Action Steps Develop and distribute stroke alert protocol sheets or notecards to all relevant stakeholders as a readily accessible resource Notify local EMS and staff across the hospital who may encounter stroke patients of protocols to ensure standardization and streamline patient entry 3 Set Goals for Quality Improvement Action Steps Track program and care quality data metrics across care pathway to measure success Work with stroke team to set specific goals for quality improvement and track program progress in reaching goals Source: Service Line Strategy Advisor research and analysis

Stroke Protocols Rising Focus on Care Continuity Driving Need for Rigorous Patient Follow-Up Post-Discharge Care, Post-Acute Transitions Necessary to Bring Down Readmission Rates Intensive Follow-Up Care Capable of Reducing Readmissions Pre-Discharge Education Patient Follow-Up Post-Discharge Coordination Outline care plan for any necessary post-acute services Educate in lifestyle changes to prevent further vascular disease Provide guidance in tackling potential further complications that may arise Call patient 30-days post- discharge to follow-up Provide medical examinations in days, months following discharge if necessary Give patient continuing education in preventing stroke readmission Work with relevant post-acute providers to create long-term care plan Coordinate long-term plan to prevent readmission Relevant documents sent to post- acute provider or PCP for continual medical management Reduction in 30-day readmission associated with nurse practitioner led follow- up visit versus no follow-up visit1 48% Study In Brief: Stroke Readmission Prevention1 Randomized clinical study found regimented in-person follow-up visits significantly reduced readmissions for those patients discharged home Patients who received a phone call within one week of discharge were more likely to attend a follow-up visit The study utilized nurse practitioners trained in a specific post-discharge, demonstrating the importance of a regimented, standardized follow-up protocol that can be employed by any practitioner on the stroke team Source: Andersen, HE et al., Can Readmission After Stroke Be Prevented? : Results of a Randomized Clinical Study: A Post-discharge Follow-Up Service for Stroke Survivors. Stroke, 2000, 31: 1038-1045. Bravata et al., Readmission and Death After Hospitalization for Acute Ischemic Stroke: 5-Year Follow-Up in the Medicare Population, Stroke 2007; 38: 1899-1994. Service Line Strategy Advisor research and analysis. Condon, C., Lycan, S., Duncan, P. & Bushnell, C. “Reducing Readmissions after Stroke With a Structured Nurse Practitioner/Registered Nurse Transitional Stroke Program,” (2016). Stroke,

Set Criteria, Pathways Key to Post-Acute Relationship Strategic Guidance Post-Acute Transitions Set Criteria, Pathways Key to Post-Acute Relationship In anticipation of the effects of health reform, hospitals are beginning to look towards building relationships with post-acute care providers in order to deliver the best experience and quality of care for patients. Programs are working to develop formalized referral relationships with hospitals, in which standardized discharge criteria and pathways are developed. Certain programs, such as the one profiled, are placing rehabilitation specialists in the acute-care setting to ease the transition to post-acute care and ensure proper triage to rehabilitation providers. The last key towards building relationships between acute and post-acute providers is data and outcomes sharing. Acute-care providers must share pre-discharge functionality measurements, and pre-surgical measurements when applicable. Similarly, post-acute providers must provide rehabilitation outcomes data with referring programs for proper follow-up. This is important for maintaining trust that the programs physicians refer patients to are continuing to provide proper care. ! Keys to Successful Post-acute Relationships: Acute-care Providers Established list of internal or external post-acute providers, depending on availability Set criteria for discharge to each level of post-acute care Individuals appointed to ease transition to post-acute setting Data and outcomes sharing between acute and post-acute providers Inpatient Rehab Facility Skilled Nursing Facility Outpatient Clinics Home Health TAKE OUT BUT Case in Brief: Everwood Rehab Physical medicine and rehabilitation hospital in Midwestern U.S. offering a range of specialties Selected rehabilitation physicians and APs work in acute-care setting to provide consults, enhance relationship with acute care providers, and ease transition into post-acute care setting Surgical and acute-care outcome measurements shared with post-acute providers Post-acute outcomes data provided to case stakeholders for follow-up and tracking Pseudonym