When a stroke patient is discharged from the hospital, they often must cope with a new disability or lack of function, so changes in their medications or a new dosing prescription can be particularly confusing. This can lead the patient to overmedicate, take the wrong medication or skip medications entirely and can result in being readmitted to the hospital.
But a pilot study that is looking at a new discharge strategy and being led by researchers at Wake Forest Baptist Medical Center, indicates that phone calls and conversations with a “stroke coach” seem to keep a patient on the road to recovery.
Cheryl D. Bushnell, M.D., associate professor of neurology and director of Wake Forest Baptist’s Primary Stroke Center, saw firsthand the need for a better hospital-to-home transition. “Many patients are not only overwhelmed with the new diagnosis of stroke, but also the risk factors that might be uncovered during the stroke hospital stay. This means new medications or adjustments to the old ones. Most important, all of the stroke education we give to people in the hospital before going home may be forgotten with everything else that happens during the hospital stay, so getting some additional teaching after getting home could help this transition.”
Bushnell, Wake Forest Baptist neurology colleague Elizabeth Sides, MEd., and colleagues from Duke University School of Medicine, followed stroke patients who were discharged from the hospital with two or more changes in their medications between admission and discharge. Their findings were recently published online in the journal BMC Public Health.*
The study followed 30 stroke patients who had a change of at least two medications between admission and discharge. The first 20 patients were selected for coach calls and the remaining patients served as a control group and did not receive coaching.
Prior to discharge, the coach reviewed a packet of information with each patient and their caregiver. The information included: specifics about when to call 911 or their physician and/or pharmacist; lifestyle suggestions to prevent stroke; a checklist of the individual patient’s risk factors with additional information about each; and a list of their current medications, what they treat and the dosage.
Within two weeks of discharge, each of the 20 study participants received a call from the medication coach who provided general information about stroke and the importance of preventing another stroke, how to mitigate their individual stroke risk factors and the importance of taking their prescribed medications. The medication coach assessed each participant’s understanding of their discharge orders by reviewing each stroke prevention medication on the participant’s discharge list, asking whether each was still taking the medication, and if not, why. The coach also determined whether the participant understood the purpose of each medication, asking how to take it, refill it, and to identify its side effects. In closing the call, the coach asked participants if they had any specific questions about their medications or stroke recovery.
Following each call, the coach forwarded medication-related questions to a pharmacist and stroke-related questions to a stroke nurse, compiled their responses and called the participant back with the information. These responses were also summarized and sent to the participant’s primary care provider. Finally, the coach summarized any lengthy answers, writing at a 7th grade level, and sent them to each participant in a follow-up letter.
At the end of three months, an interviewer contacted all study subjects to hear how participants had fared. Overall, researchers found very little difference between the coaching and control group when it came to knowledge of medications and stroke. However, more participants in the coaching group (93.8 percent) knew what to do if problems or symptoms worsened than the control group (77.8 percent) and a significantly larger number of coaching participants (93.8 percent) had seen their primary care provider since discharge than those in the control group (60 percent). In addition, there were trends toward lower depression severity scores in the intervention group, higher reported health status scores and lesser disability among those in the control group.
While recognizing the limitations of a small study, Wake Forest Baptist researchers believe the overwhelmingly positive feedback from participants about the post-discharge coaching, the feasibility of adding this element to discharge plans, and the early influence on keeping follow-up appointments with their primary care providers show the promise of this type of program.
Co-authors include Eric D. Peterson, M.D., Louise O. Zimmer, MPH, Leslie Wilson, B.S., and Wenqin Pan, Ph.D., all of Duke Clinical Research Institute, Duke University School of Medicine, and DaiWai M. Olson, Ph.D., Department of Medicine, Division of Neurology, Duke University Medical Center.
Competing Interests: Dr. Bushnell receives research salary support from NIH/NINDS K02 NS058760, but this funded research is not related in any way to the study presented in this manuscript. Dr. Peterson received salary support from the Agency for Health Care Research Quality, the funding source for this study. None of the other coauthors have any competing interests to disclose.
Acknowledgements: This project was supported by grant number U18HS016964 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors would like to thank Patricia Frazier, MA for enrolling participants, Judith A Stafford, MS for statistical programming, Charlie Stoner, PharmD, BSN, for triaging pharmacy questions and Bob Sanderford for data entry.
Wake Forest Baptist Medical Center