Massachusetts Coverdell Program
From 2012 to 2015, Massachusetts achieved significant improvements in the percentage of patients for whom an NIHSS score was recorded (73% to 84%, P < .0001) and who were screened for dysphagia (82% to 86%, P < .0001) in 56 participating hospitals through educational opportunities for hospitals and EMS agencies and technical assistance for data-driven QI.
In 2004, the Massachusetts Department of Public Health received funding from the CDC Paul Coverdell National Acute Stroke Program and has been funded for each subsequent program cycle. The Massachusetts Coverdell Program began by developing two collaborative QI groups: the Stroke Collaborative Reaching for Excellence (SCORE) for hospitals and the EMS QI Collaborative for EMS agencies. Data from the Coverdell registry complemented the activities of these collaborative QI groups by providing insights on trends in stroke patient care. In 2012, the Massachusetts Coverdell Program expanded efforts by collaborating with key partners to link facilities in the post-acute care setting with the wider data-driven QI initiative of the Massachusetts stroke system of care. The Massachusetts Coverdell Program was the only grantee to work in all three settings of stroke care, including EMS, in-hospital, and post-hospital transitions of care during 2012–2015.
The Massachusetts Coverdell Program engaged in three key QI activities: (1) stroke system of care learning sessions, (2) regional meetings, and (3) technical assistance in data-driven QI.
Stroke systems of care learning sessions were in-person, semiannual, day-long conferences with breakout sessions on various topics, including hospital best practices, EMS feedback, the time last known well variable, and chronic disease self-management. The Massachusetts Coverdell Program arranged to provide continuing medical education credits to participants, who included staff from EMS agencies, hospitals, and skilled nursing facilities.
In addition to learning sessions, the Massachusetts Coverdell Program held in-person, semiannual regional meetings for each of the three collaborative groups related to specific care settings. Regional meetings offered networking opportunities and were less formal than learning sessions, with relevant announcements; data review; and discussion of challenges, successes, and effective QI tools.
Program staff used registry data to create individual hospital performance reports, inform learning sessions and regional meetings, and track specific measures that reflect practice changes, such as pre-notification rates and documentation of time last known well. The Massachusetts Coverdell Program post-acute QI specialist visited the skilled nursing facilities to provide technical assistance that included stroke education, data abstraction training, and coaching.
“When we started recruiting nursing home facilities, we told them they had to develop a stroke team… Now they are all in the beginning stages of QI projects. I was just meeting with one facility that is excited about their QI project and hoping to be able to present it to all of us in September when we get some results.” — Program Staff Member
Massachusetts Coverdell Program’s QI efforts contributed to practice and systems changes across the stroke care continuum. Major achievements in the EMS and hospital settings included development of a new statewide EMS Stroke Alert Protocol and creation of an EMS feedback form to help hospitals and EMS agencies work together to improve quality of care and care transitions. In the post-acute care setting, the Massachusetts Coverdell Program developed the framework for a Post-Acute Quality Improvement Collaborative similar to those for EMS agencies and hospitals, invited skilled nursing facilities to their learning sessions, deployed a post-acute care transition specialist, and created an educational module for skilled nursing staff.
QI activities and focused technical assistance also contributed to better quality of care for stroke patients. Performance measure data from the state stroke registry of participating hospitals revealed improvements in 6 of the 12 key Coverdell Program quality-of-care measures from 2012 to 2015 (Table 1). The two measures that had the largest increases over time were the percentages of eligible patients screened for dysphagia and for whom an NIHSS score was recorded, which increased 4% and 11%, respectively.
Table 1. Improved Coverdell Program Quality of Stroke Care Measures, 2012–2015
|Screened for dysphagia||82%||86%||<.0001|
|Venous thromboembolism (VTE) prophylaxis||96%||98%||<.0001|
|Discharged on statin medication||94%||97%||<.0001|
|Anticoagulation therapy for atrial fibrillation/flutter||95%||98%||<.01|
|Recording of NIHSS score||73%||84%||<.0001|
Future work includes a plan to link data across the stroke system of care from EMS agencies to hospitals to post-hospital facilities, as well as continued program monitoring through inventory surveys and dissemination of facility-specific reporting, which provides feedback in identifying opportunities for continued improvement. Establishing data linkages that accommodate patient confidentiality requirements will be key to achieving an integrated, high-performing stroke system of care across the care continuum in Massachusetts. The Massachusetts Coverdell Program received 2015–2020 Coverdell funds to continue its work in stroke care.
Acronyms Used in the Summaries
CDC: Centers for Disease Control and Prevention
EMS: Emergency Medical Services
NIHSS: National Institutes of Health Stroke Scale
NQF: National Quality Forum
QI: Quality Improvement
Other Terms Defined
Primary Stroke Center: The Joint Commission’s Certificate of Distinction for Primary Stroke CentersExternal recognizes centers that make exceptional efforts to foster better outcomes for stroke care. Achieving certification signifies that the services provided have the critical elements to achieve long-term success in improving outcomes. The certification is based on the Brain Attack Coalition’s “Revised and Updated Recommendations for the Establishment of Primary Stroke CentersExternal” and includes the requirement to report on eight core standardized measures from the Joint Commission.