HCM 4040 Module 6 Final Project Example

Many Hands, One Discharge: How Each Discipline Contributes to Getting Stroke Patients Home From a Rehabilitation Hospital

Student Name

B.S. in Healthcare Management, Thomas Edison State University

HCM-4040: Healthcare Quality and Outcomes: Measurement and Management

Mentor Name

Month Day, Year

Many Hands, One Discharge: How Each Discipline Contributes to Getting Stroke Patients Home From a Rehabilitation Hospital

The final project for this course asks how the people who deliver healthcare can work together, each contributing insight from their own expertise, to produce quality care. This paper answers that question for one result at one organization. Rancocas Valley Rehabilitation Hospital, an invented 58-bed facility in Burlington County, has seen the share of stroke patients discharged to the community slip from 71% to 64% over three quarters, while their functional gains held steady. Earlier analysis suggested the problem lies less in therapy than in the preparation for going home. Getting a stroke survivor home depends on at least seven disciplines and a family, and no one of them can do it alone. The sections below describe what each contributes, review evidence on team functioning and family training, propose changes to how the hospital organizes the collaboration, and set out how the results will be measured.

The Problem in Context

Discharge to the community is one of the outcome measures Medicare publishes for every rehabilitation facility, and it matters more to patients than almost any other result. It is also the measure most exposed to factors beyond the therapy gym: whether a caregiver is available and confident, whether the home has stairs or a tub the patient cannot use, whether medications can be managed and whether outpatient therapy and equipment are arranged. Case reviews of 30 recent stroke patients who went to a nursing facility instead of home found that in 11 the family had been willing but felt unprepared, in seven the home had not been assessed until the final week, and in five a late change in medications or diet raised concern among family members about managing at home. These are coordination failures, and they point to the way the team works rather than to any one discipline.

What Each Discipline Contributes

The table summarizes the distinctive insight each discipline brings to the discharge and the specific contribution the hospital now expects from it.

Evidence on How Teams Contribute

Strasser et al. (2005) studied 46 rehabilitation teams in Veterans Affairs hospitals, involving 530 staff from six disciplines and 1,688 stroke patients. Teams whose members rated them higher on task orientation, order and organization, and the usefulness of quality information achieved greater functional improvement in their patients. None of the team measures predicted whether patients went home, a finding that suggests discharge destination depends on more than how the team works internally. For Rancocas Valley, the study supports investing in structured, data-informed conferences, but warns that better teamwork alone will not move the discharge measure unless it reaches families and homes.

Research on deliberate efforts to strengthen collaboration across professions gives less to stand on. Reeves et al. (2017) reviewed nine trials of practice-based interventions, including team action planning, interprofessional rounds, meetings and checklists, and judged the certainty of evidence to be low to very low, too weak to draw firm conclusions about effects on patient outcomes. That is a reason to measure the hospital's own results carefully rather than to assume that new meetings will help.

Families as Members of the Team

Families are the team members who stay after discharge, and their confidence often decides whether a patient goes home. Kalra et al. (2004) randomized 300 stroke patients and their caregivers in a London stroke rehabilitation unit; caregivers who received hands-on training in basic nursing and personal care reported less burden, anxiety and depression, and costs over the following year were lower, although patients' disability and institutionalization did not change. A much larger later trial was less encouraging. Forster et al. (2013) tested a structured caregiver training program across 36 stroke units in England and found no difference in patients' daily activities or caregivers' burden at six months. Read together, the two trials suggest that a training program delivered as a checklist may not help, while individual, practical preparation built around a particular family and home is still worth pursuing.

Rancocas Valley's response is a family training day scheduled in the second week of the stay rather than the last. Each discipline teaches the family the specific tasks it owns, the family practices them under supervision, and the team notes what the family still finds hard. The case manager then plans support for those tasks, such as home health visits or a later start for the caregiver's return to work.

Organizing the Collaboration

Medicare's coverage rules already require rehabilitation facilities to hold an interdisciplinary team conference for each patient every week, so the structure exists. The proposal changes what happens inside it. First, the discharge destination and the family plan become fixed agenda items from the first conference, with a target date. Second, the quality analyst adds a one-page panel to each conference showing the unit's discharge-to-community rate and the status of each patient's home assessment, family training and outpatient referrals, giving the team the kind of quality information Strasser et al. linked to better results. Third, any discipline can flag a discharge risk, and a flagged risk must have an owner and a date before the conference ends.

At the organizational level, the quality council sponsors the change, the stroke program medical director leads it, and the director of case management owns the measure. Barriers are predictable: therapists' time is counted in billable minutes, family training competes with therapy sessions, and some families can only visit on weekends. The hospital will therefore staff one Saturday training session a month, and conference time is protected in every discipline's schedule.

Measuring Whether It Works

The primary measure is the monthly share of stroke patients discharged to the community, tracked on a run chart with an aim of returning to 71% within nine months. Process measures will show whether the collaboration is happening: the share of patients with a home assessment by day 14, the share with a completed family training day, and the share whose medications were finalized three days before discharge. A balancing measure, readmissions within 30 days, will show whether patients sent home were truly ready. Because Reeves et al. found the evidence on collaboration interventions uncertain, the team will review these measures quarterly and drop any change that adds work without moving the results.

Conclusion

No single discipline gets a stroke survivor home. The physician sets the medical course, nurses and therapists build the skills, the speech-language pathologist keeps meals and conversations safe, the pharmacist makes the medicines manageable, the case manager arranges what happens next, and the family carries all of it into the house. The evidence suggests that how a team organizes its work and uses quality information affects patients' recovery, but that getting patients home also requires reaching beyond the hospital to families and homes. By turning the weekly conference into a place where the discharge is planned from the first week, preparing families early and measuring both process and results, Rancocas Valley gives every discipline a defined part in the outcome that matters most to its patients.

References

Forster, A., Dickerson, J., Young, J., Patel, A., Kalra, L., Nixon, J., Smithard, D., Knapp, M., Holloway, I., Anwar, S., & Farrin, A. (2013). A structured training programme for caregivers of inpatients after stroke (TRACS): A cluster randomised controlled trial and cost-effectiveness analysis. The Lancet, 382(9910), 2069-2076. https://doi.org/10.1016/S0140-6736(13)61603-7

Kalra, L., Evans, A., Perez, I., Melbourn, A., Patel, A., Knapp, M., & Donaldson, N. (2004). Training carers of stroke patients: Randomised controlled trial. BMJ, 328(7448), 1099. https://doi.org/10.1136/bmj.328.7448.1099

Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 2017(6), Article CD000072. https://doi.org/10.1002/14651858.CD000072.pub3

Strasser, D. C., Falconer, J. A., Herrin, J. S., Bowen, S. E., Stevens, A. B., & Uomoto, J. (2005). Team functioning and patient outcomes in stroke rehabilitation. Archives of Physical Medicine and Rehabilitation, 86(3), 403-409. https://doi.org/10.1016/j.apmr.2004.04.046