Challenges Implementing An Innovative Home Health Evaluations And Active Living Program

Introduction: Approximately 50% of stroke patients are discharged to home from the hospital. Post stroke transitional care is fragmented and unorganized leading to poor patient outcomes, hospital readmissions, decreased functional status, and increased caregiver burden. We discuss our experience implementing a multidisciplinary team-based post stroke transitional telehealth program. Methods: Acute stroke patients discharged home were invited to participate in a 90-day telehealth program, iHEAL, upon discharge. Inclusion criteria included 2 or more uncontrolled risk factors requiring medication management, two or more therapy needs, WiFi at home, knowledge of technology, and agreement to follow up with iHEAL program providers. Patients were discharged with remote monitoring devices (blood pressure monitor, medication adherence device) and an iPad for telehealth visits with the stroke NP and both the neurology pharmacist and therapists. Surveys were completed by participants during and after completion of the program. Results: Of approximately 167 patients discharged home within the initial 9 months, 6 patients enrolled in iHEAL. The most common reasons for ineligibility were lack of two therapy needs and lack of two risk factors in need of medication adjustment excluding 69% of patients when combined in addition to limited internet access in the home. There have been no readmissions. Medications were scanned 50% of the time. Blood pressure readings were maintained or decreased for all patients. Telehealth visit completion: 50% NP, 40% Pharmacist , 40% PT, 20% OT and 40% SLP. Most reported feeling comfortable using the iHEAL equipment (80%) and 100% reported satisfaction with the program and would recommend to others. Conclusion: Enrollment in iHEAL has been unexpectedly difficult due to overly stringent enrollment criteria and limited broadband internet access in Central Virginia and surrounding regions. These difficulties led to changing criteria in Month 10 to one therapy need and removing the requirement for medication management of the two identified risk factors. Follow up data to be included in final presentation.