Call for Navigation: Charting a Course for Stroke Survivors

Approximately 130,000 Americans will die from stroke this year. Another 795,000 people will suffer a stroke and live to join the 6.5 million stroke survivors in the United States today. Many will struggle with long-term disability, isolation and confusion. Nearly two-thirds of Medicare beneficiaries discharged after an ischemic stroke die or are rehospitalized within one year (Stroke 2011;42[1]:159-66). In the United States, the cost of stroke—including healthcare services, medications and lost productivity—totals $34 billion annually (Circulation 2015;131:e29-e322). 

Today’s stroke statistics are a drop in the bucket compared with the “stroke tsunami” that the National Stroke Association (NSA) says will accompany the aging of the baby boomers. By 2030, the prevalence of stroke will increase by 3.4 million people relative to 2012 and direct medical stroke-related costs will triple, according to American Heart Association/American Stroke Association projections (Stroke 2013;44:2361-2375). Improving how stroke survivors reintegrate into their communities and access resources needs to be a priority, says Amy Nieberlein, MSN, ACNP-BC, FNP-C, CEN. She talked with Cardiovascular Business about the NSA Stroke Recovery Navigator Program she’s helping to pilot at Swedish Medical Center in Denver.

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What is the goal of the Stroke Recovery Navigator Program?

Put simply, the goal is make sure patients are equipped to handle life as stroke survivors. That means helping patients and their caregivers access resources that will improve their health outcomes and quality of life after they leave the hospital.

How did the pilot program work at your hospital?

During rounds, the other nurses and I told the patients about the program. The patients who agreed to participate were assigned to an NSA navigator who performed an initial needs assessment for each participant and identified community resources that matched his or her needs. The navigator worked with them for up to six months after hospital discharge.

What did the navigators do?

The navigators mostly provided telephone support to the stroke patients and their caregivers. Depending on the resources available and each patient’s needs, they might help with medication questions, address transportation barriers, make connections with stroke support groups and help them tackle the challenges associated with returning to work or activities of daily living. They also reinforced the education that we convey to all stroke patients when they’re discharged, including risk factor management and why it’s critical to seek immediate medical attention for stroke symptoms.

How was success measured?

The NSA set goals for several metrics for success, such as better than the national average for rehospitalization and improved scores on indexes for normal living reintegration (for patients) and reduced burden (for caregivers). For the most part, the program exceeded NSA’s goals for phase 1.

As a pilot site, we didn’t get to see the metrics for our group of patients specifically—we will in phase 2, which will be helpful—but I feel sure our patient satisfaction metrics would be up for the patients in this program, because it makes them feel empowered.

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Based on your experience with patient care, what is the key to success for transition-to-home programs like this one?

The navigators start where the patient is. Where the process begins and how it moves forward are both highly individualized. There’s no way our hospital, which is a telemedicine hub serving eight states, could provide that kind of service to all of our patients, but trained navigators can get to know the patients and the resources their communities offer, and then match them. 

How did participating in the program affect your daily work?

Swedish Medical Center was one of three hospitals that participated in phase 1 of the pilot. Before patients were discharged from the acute care setting, we invited them to join the program. If they were interested, we sent their information to the NSA navigator assigned to our hospital. It didn’t add much work for us, and there were no costs for us to participate.

Based on your experience, which patients would you expect to benefit from a navigator program like this one?

You get to know your patients and get a sense for which ones will be engaged in their care. Patients with engaged family members seemed more likely to join the program, but I actually think the program would be even more valuable for patients who don’t have that network of support. In some ways, they need more resources than patients with engaged families.

Do you think this program or others like it would work on a national level? What would be your approach?

I think so, because stroke is already the leading cause of disability in the United States. That’s going to get worse with the stroke tsunami. Programs like this can help our patients with secondary prevention and community education. Being process-dependent, not person-dependent, is going to be key with any door-to-community reintegration program. And, of course, we need to create greater public awareness of stroke symptoms. Unlike a heart attack, a stroke doesn’t always hurt when it’s happening, but its impact can be devastating.