Rates of stroke mortality improved substantially for decades, driven by the increasing effectiveness of inpatient treatment for acute stroke, in particular fibrinolytic treatment for ischemic stroke in the 1990s, and improvements in population rates of smoking and blood pressure control (Ormseth, Sheth, Saver, Fonarow, & Schwamm, 2017; Yang et al., 2017). However, progress on stroke mortality began to stall or reverse in 2013, with worse outcomes concentrated among Black and Hispanic patients (Yang et al., 2017). The Centers for Disease Control and Prevention has called on hospital systems to respond to this trend by improving care coordination across stroke systems of care (Yang et al., 2017).
Thomas Bodenheimer framed an influential definition of care coordination in a landmark 2008 article in which he described the root causes of care fragmentation as a) weak primary care unable to coordinate treatments for patients b) fee-for-service payment rewarding isolated episodes of care rather than patient-centered collaboration c) Poor communication between providers, driven by lack of collaboration and poor EHR interoperability (Bodenheimer, 2008). This framework drew on Naylor’s development of the Transitional Care Model as a best practice for nursing care to improve coordination across discharge (M. D. Naylor et al., 2011; M. Naylor & Keating, 2008).
There is expert consensus that a lack of coordination is an important problem in the prevention and treatment of stroke (Broderick & Abir, 2015). However, a meta-analysis of care coordination efforts for stroke in the United States found that less than half had a positive impact on readmissions or adverse events (Puhr & Thompson, 2015). With best practices uncertain, there is enormous variation across hospital networks in terms of the intensity and type of care coordination models in place, ranging from none to multiple overlapping models (Abir et al., 2015).
Aims: This research responds to the call from a lead editorial in the journal Neurology which declared: “understanding the existing flow (of stroke patients) is an important first step in determining where stroke care can be improved ((Majersik & Youngquist, 2018).” To approach this understanding, the research will apply the case study method to describe the organization, delivery and financing of the process of care for stroke organized around a hospital in an urban neighborhood. By assembling a case study from interviews with health care providers and administrators across the continuum of care for stroke, the researchers aim to identify diverse perspectives on opportunities to improve continuity of care, and explore the dynamics and intentions that lead to discontinuity and missed opportunities for improvement (Yin, 2009).
Methods: This research is a descriptive phenomenological case study with providers and stakeholders involved in the continuum of stroke care at the hospital. Ten to fifteen providers and stakeholders will be recruited through snowball sampling beginning with the coordinating nurse of the Stroke Center. Data collection will consist of semi-structured interviews with participatory diagramming of the stroke continuum of care (Umoquit, Tso, Burchett, & Dobrow, 2011). The interviews will be guided by a instrument that has been developed with input from content experts and Bodenheimer and Naylor’s care coordination frameworks (Bodenheimer, 2008; M. D. Naylor et al., 2011). The analysis plan is a thematic analysis using Colaizzi’s 8-step method to identify fundamental structures (Wirihana et al., 2018). Data analysis will rely on peer debriefing to promote dependability, credibility and confirmability. The credibility of data will be maximized through prolonged engagement, comprehensive field notes and participant validation (Yin, 2009).
Implications: The findings from this study may generate insights and hypotheses on the barriers to care coordination and system dynamics related to stroke care and prevention. These insights and hypotheses may contribute to the development of future quantitative research on coordination of care for stroke. In addition, these insights may assist health care systems in urban neighborhoods to tailor care coordination models to overcome fragmentation in the care for stroke and improve outcomes in the urban context.
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