Michigan’s Ongoing Stroke Registry to Accelerate Improvement of Care (MOSAIC)
From 2012 to 2015, Michigan’s Ongoing Stroke Registry to Accelerate Improvement of Care (MOSAIC) achieved significant improvements in the percentage of patients for whom an NIHSS score was recorded (82% to 91%, P < .0001) and who were provided with stroke educational materials (86% to 95%, P < .0001) in 26 hospitals through monthly conference calls on best practices and one-to-one technical assistance for hospitals.
During 2007–2012, the Michigan Department of Community Health received funding from the CDC Paul Coverdell National Acute Stroke Program to improve care for stroke patients in hospitals participating in MOSAIC. The Michigan Department of Community Health’s experience with in-hospital stroke care and prior pilot work on hospital-to-post-hospital transitions of care provided the program with the organizational capacity needed to receive 2012–2015 Coverdell funds to continue its work.
MOSAIC’s main QI activities were (1) continuing or maintaining improvement on key inpatient stroke care measures and (2) conducting a pilot program of making 30-day follow-up calls for all patients discharged.
MOSAIC continued to collect data on inpatient stroke care measures and provide progress reports for 26 participating hospitals to maintain the hospitals’ gains on these measures. Hospitals then selected activities to address potential areas for improvement. MOSAIC QI staff assisted hospitals through one-on-one discussions during site visits and by presenting best practices during monthly conference calls.
MOSAIC’s work in the post-hospital setting centered on developing and piloting a 30-day follow-up call process for patients discharged home. Through collaboration with participating hospitals, program staff created a call sheet to identify the problems that patients commonly experience that could result in readmissions. MOSAIC piloted the protocol in 5 of the 26 Coverdell-participating hospitals, and QI specialists helped hospitals use call data to identify areas where they could improve their clinical processes to reduce the readmission rate. For example, hospitals changed discharge and patient education processes to help patients better understand their diagnosis, medication regimens, and stroke preventive measures.
“…the quality is improved, and even formatively the relationships are improving between the discharge [hospital discharge staff] and the primary care community and the physician understanding… And some of these issues that physicians didn’t know about. They had no way to get this information. It [the follow-up call system] has provided a platform.” — Program Staff Member
MOSAIC’s QI efforts contributed to systems and practice changes in hospitals participating in the 30-day follow-up call pilot. For example, at one participating hospital, follow-up call data revealed that patients were not meeting lifestyle and medication regimen recommendations. To overcome this challenge, the hospital began providing free medication counseling services that focused on working with the patient and caregiver to set up a medication regimen before discharge.
MOSAIC’s activities also contributed to better quality of care for stroke patients. Performance measure data from the state stroke registry of participating hospitals revealed improvements in 4 of the 12 key Coverdell Program quality-of-care measures from 2012 to 2015 (Table 1). The two measures that made the largest increases over time were the percentages of patients provided with stroke education at discharge and for whom an NIHSS score was recorded, which both improved 9%.
Table 1. Improved Coverdell Program Quality of Stroke Care Measures, 2012–2015
|Venous thromboembolism (VTE) prophylaxis||97%||99%||<.0001|
|Discharged on statin medication||91%||93%||<.0001|
|Recording of NIHSS score||82%||91%||<.0001|
MOSAIC’s future work will focus on continuing the record of success with inpatient and post-hospital stroke care, as well as informing the passage of guidelines to establish a statewide stroke system of care, including hospital designation for primary stroke centers. MOSAIC plans to expand the patient discharge 30-day follow-up call process and resulting system changes to additional Coverdell hospitals; however, they are largely dependent on Coverdell funding for stroke care programming. MOSAIC received 2015–2020 Coverdell funding 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.