Reducing Stroke Readmission Through the Implementation of Telehealth

Practice Problem: Readmission occurs frequently among patients with stroke and because of this, the Centers for Medicare and Medicaid Services (CMS) have imposed programs to reduce 30-day readmissions among hospitals. The health care system must respond with transition of care, especially during the period of recent stroke to improve patient outcomes. PICOT: The PICOT question that guided this project was among patients with a recent diagnosis of stroke (P), what is the effect of a telehealth appointment with a nurse practitioner (NP) for post discharge follow-up (I), compared to a standard face-to-face clinic appointment (C), on 30-day readmissions rates (O), within two months (T)? Evidence: Stroke is the fourth leading cause of death and has a readmission rate of 14%. Past studies have demonstrated the effectiveness of telehealth in treating patients outside of the hospital setting, which suggests the potential of telehealth on post-discharge follow-up care. Intervention: To assess the impact of telehealth on 30-day readmission rates, stroke patients received a telehealth follow-up phone visit by a NP within ten days of being discharged to home. Outcome: Data was collected from participant’s electronic health records (EHR) and discharge databases from October 13 to November 13, 2020. Among participants, the implementation of telehealth visits demonstrated a reduced readmission rate of 6.25% for stroke patients. Conclusion: Telehealth is an effective, sustainable, and widely implementable strategy to provide post-discharge care to patients. This study outlined a framework to further analyze the effectiveness of telehealth visits in reducing 30-day readmission rates among stroke patients. REDUCING STROKE READMISSION 3 Reducing Stroke Readmission Using Telehealth Healthy People 2020 strives to address the lack of access to healthcare, particularly among certain populations challenged by lack of insurance, cost, cultural competence, proximity to hospitals, and other social issues posing barriers to access (Healthy People 2020, 2019). The inability to readily access healthcare creates a foundation for negative outcomes impacting the rate of recovery, quality of life, and financial strain on hospitals that manage such populations. Programs developed by the Centers for Medicare and Medicaid Services (CMS) such as the Hospital Readmissions Reduction Program (HRRP), which aim to improve quality by impacting reimbursement rates for hospitals with high 30-day readmission rates, further impose strain among hospitals. Recent events created an increased demand to connect with patients using telehealth by bringing access to medical care wherever the patient is located (Serper & Volk, 2018). The purpose of this evidence-based practice (EBP) project was to illustrate the implementation of telehealth in the outpatient care setting as a modality to increase access to care among patients who recently sustained a stroke and to reduce readmission rate within 30-days post discharge. This project previewed EBP and literature review to support the use of telehealth among stroke populations and identified a theoretical framework to support the implementation of a successful change project. This paper discussed evidence search strategies used and findings for common themes. The practice setting, overview, recommendation, methodology, and evaluation were also included with a plan for project dissemination. Significance of the Practice Problem Readmission rates represent a key quality indicator of healthcare services (Fisher et al., 2014). In the United States (US), avoidance of 30-day readmission is a top priority because of HRRP and federal guidelines under the Affordable Care Act of 2010 (Gai & Pachamanova, REDUCING STROKE READMISSION 4 2019). Measurement of 30-day readmission to assess the quality of care was also a recommendation by the Agency of Healthcare Research and Quality (AHRQ) in the United States (Ross et al., 2017). Hospitals received financial penalties if they demonstrate high recurrence of 30-day readmission rates (Vahidy et al., 2017). Readmission occurs frequently among stroke survivors (The Global Burden Disease [GBD] Lifetime Risk of Stroke Collaborators, 2016). In the past, stroke has been a leading diagnosis in readmission accounting for 25% of incidents during the first year of diagnosis (Gorelick, 2019). Poston (2018) found a 12% unplanned readmission within one month of discharge among patients with ischemic stroke. According to California Health and Human Services (CHHS), the national readmission rate is 14% for stroke patients, thus, these readmissions resulted in a cost of about 500 million dollars to CMS (Gorelick, 2019). Unplanned readmissions among patients with stroke happen due to various medical reasons one-month postdischarge such as kidney and urinary infection, pneumonia, health failure, and electrolyte imbalances (Nouh et al., 2017). Readmission is also attributed to patients missing their follow up appointments due to debility and fatigue after hospitalization (Boehmn et al, 2015). With a movement towards shortened length of hospitalization, patients with stroke are discharged with limited inpatient rehabilitation programs (Hicks & Cimarolli, 2018). Stroke is a debilitating event requiring close medical follow up to mitigate further complications (Driessen et al., 2016). Globally, stroke incidence affects 15 million patients annually and represents the second largest cause of death following heart disease (Gorelick, 2019). According to the GBD study in 2016, stroke is the leading cause of disability worldwide with approximately 80 million survivors requiring post stroke care (World health Organization [WHO], 2018). Five million people REDUCING STROKE READMISSION 5 worldwide live with permanent disabilities from stroke (World Stroke Organization [WSO], 2016). Nationally, stroke comprises the fourth leading cause of death (Center for Disease Control [CDC], 2018). Annual statistics in the US show approximately 800,000 American adults have suffered from a stroke (WSO, 2016). The estimated cost of healthcare services, medicines to treat stroke, and missed days of work is estimated at $34 billion annually (CDC, 2019). Locally, the incidence of stroke is 80-90 people per 100,000. As part of a complex Los Angeles health care system, the identified health care agency directs a stroke system of care that manages stroke patients for both acute and rehabilitation needs. This safety net facility houses an inpatient stroke unit with 24 beds, sees an average of six discharges per week, and operates an outpatient medical home service with 120 unique patients served weekly (Rancho, n.d.). In comparison to the national readmission data, the Los Angeles health care system has an 18% readmission rate for patients with stroke who generally endure socio-economic disadvantages, such as lack of financial support to arrange for a clinic transportation or lack of familial support (Lacounty.gov). Patients with stroke are burdened with the sequela of long-term disability impacting mobility, loss of independence, income, or employment, with a lifetime cost of stroke per person of $105,000 (Johnson, Bonafede, & Watson, 2016; Terman et al., 2018). The average cost of hospitalization involving stroke is $23,000 and varies greatly by the type of stroke, diagnosis status, and co-morbidites, such as hypertension or diabetes (Wang et al., 2013). The health care system must respond with transition care, especially during the period of recent stroke, and complex care needs further complicate stroke-related disabilities (Terman et al., 2018). Providing telehealth as a follow up intervention after discharge offers a way to reduce readmission among patients with stroke (Hicks & Cimarolli, 2018). REDUCING STROKE READMISSION 6


Reducing Stroke Readmission Using Telehealth
Healthy People 2020 strives to address the lack of access to healthcare, particularly among certain populations challenged by lack of insurance, cost, cultural competence, proximity to hospitals, and other social issues posing barriers to access (Healthy People 2020, 2019). The inability to readily access healthcare creates a foundation for negative outcomes impacting the rate of recovery, quality of life, and financial strain on hospitals that manage such populations.
Programs developed by the Centers for Medicare and Medicaid Services (CMS) such as the Hospital Readmissions Reduction Program (HRRP), which aim to improve quality by impacting reimbursement rates for hospitals with high 30-day readmission rates, further impose strain among hospitals. Recent events created an increased demand to connect with patients using telehealth by bringing access to medical care wherever the patient is located (Serper & Volk, 2018). The purpose of this evidence-based practice (EBP) project was to illustrate the implementation of telehealth in the outpatient care setting as a modality to increase access to care among patients who recently sustained a stroke and to reduce readmission rate within 30-days post discharge. This project previewed EBP and literature review to support the use of telehealth among stroke populations and identified a theoretical framework to support the implementation of a successful change project. This paper discussed evidence search strategies used and findings for common themes. The practice setting, overview, recommendation, methodology, and evaluation were also included with a plan for project dissemination.

Significance of the Practice Problem
Readmission rates represent a key quality indicator of healthcare services (Fisher et al., 2014). In the United States (US), avoidance of 30-day readmission is a top priority because of HRRP and federal guidelines under the Affordable Care Act of 2010 (Gai & Pachamanova, 2019). Measurement of 30-day readmission to assess the quality of care was also a recommendation by the Agency of Healthcare Research and Quality (AHRQ)

in the United
States (Ross et al., 2017). Hospitals received financial penalties if they demonstrate high recurrence of 30-day readmission rates (Vahidy et al., 2017).
Readmission occurs frequently among stroke survivors (The Global Burden Disease [GBD] Lifetime Risk of Stroke Collaborators, 2016). In the past, stroke has been a leading diagnosis in readmission accounting for 25% of incidents during the first year of diagnosis (Gorelick, 2019). Poston (2018) found a 12% unplanned readmission within one month of discharge among patients with ischemic stroke. According to California Health and Human Services (CHHS), the national readmission rate is 14% for stroke patients, thus, these readmissions resulted in a cost of about 500 million dollars to CMS (Gorelick, 2019). Unplanned readmissions among patients with stroke happen due to various medical reasons one-month postdischarge such as kidney and urinary infection, pneumonia, health failure, and electrolyte imbalances (Nouh et al., 2017). Readmission is also attributed to patients missing their follow up appointments due to debility and fatigue after hospitalization (Boehmn et al, 2015). With a movement towards shortened length of hospitalization, patients with stroke are discharged with limited inpatient rehabilitation programs (Hicks & Cimarolli, 2018). Stroke is a debilitating event requiring close medical follow up to mitigate further complications (Driessen et al., 2016).
Globally, stroke incidence affects 15 million patients annually and represents the second largest cause of death following heart disease (Gorelick, 2019). According to the GBD study in Locally, the incidence of stroke is 80-90 people per 100,000. As part of a complex Los Angeles health care system, the identified health care agency directs a stroke system of care that manages stroke patients for both acute and rehabilitation needs. This safety net facility houses an inpatient stroke unit with 24 beds, sees an average of six discharges per week, and operates an outpatient medical home service with 120 unique patients served weekly (Rancho, n.d.). In comparison to the national readmission data, the Los Angeles health care system has an 18% readmission rate for patients with stroke who generally endure socio-economic disadvantages, such as lack of financial support to arrange for a clinic transportation or lack of familial support (Lacounty.gov). Patients with stroke are burdened with the sequela of long-term disability impacting mobility, loss of independence, income, or employment, with a lifetime cost of stroke per person of $105,000 (Johnson, Bonafede, & Watson, 2016;Terman et al., 2018). The average cost of hospitalization involving stroke is $23,000 and varies greatly by the type of stroke, diagnosis status, and co-morbidites, such as hypertension or diabetes (Wang et al., 2013). The health care system must respond with transition care, especially during the period of recent stroke, and complex care needs further complicate stroke-related disabilities (Terman et al., 2018). Providing telehealth as a follow up intervention after discharge offers a way to reduce readmission among patients with stroke (Hicks & Cimarolli, 2018).

PICOT Question
The PICOT question that will be addressed is: Among patients with a recent diagnosis of stroke (P), what is the effect of a telehealth appointment with a nurse practitioner (NP) for post discharge follow-up (I), compared to a standard face-to-face clinic appointment (C), on 30-day readmissions rates (O), within two months (T)?
The population selected was composed of adult patients recently diagnosed with a stroke resulting in a physical impairment. These patients were offered a telehealth encounter with the NP within two weeks of being discharged from the hospital instead of the standard practice of a face-to-face clinic appointment to address concerns since hospitalization. The patient was given a time and date when telehealth will transpire. The facility has a standard practice to give patients a post-discharge follow-up with a 40-minute appointment to complete the encounter.
CMS requires a transition of care process be in place to account for patients after they are discharged. This may include care coordination with a registered nurse (RN) to manage the patient after discharge, such as reviewing medications adherence (Poston, 2018). As an outcome, the practice change explores the adaptation of telehealth phone visits to increase access to care outside of a clinic setting (Henderson, Davis, Smith & King, 2014). With the use of telehealth, the NP can address patients' concerns and deliver just-in-time care, which may avoid readmission to the hospital (Poston, 2018). The timing of the project will evaluate the impact of using telehealth phone visits on reducing readmission within sixty days after the implementation of the practice change.

Theoretical Framework and Change Theory
The evidence-based practice (EBP) frameworks and theories are used to explain how a telehealth phone visit is an intervention for following up with patients post stroke. Telehealth nursing renders a chance to transform the art of caring and healing (Caroll, 2018). In describing the NP practice, interaction between the patient and the NP in the clinical setting focuses on identifying patient goals and agreeing on a plan to accomplish set goals (Henderson, Davis, Smith, & King, 2014). The nursing profession embraces EBPs urging the use of evidence-based research to support their decisions in the clinical setting and to improve patient outcomes (Doody & Doody, 2013). The seven-step EPB model, known as the Iowa model, gives guidance in identifying an issue in the practice setting and identifying interventions supported by literature that are evidence-based in pursuit of change in nursing practice (Brown, 2014). The first three steps involve identifying a focused problem, prioritizing the problem within an organization, and assembling an interdisciplinary team to develop, implement, and evaluate EBP change. Steps four and five involve gathering, evaluating, and critiquing relevant studies that support the PICOT question.
Step six involved pilot implementation in a practice setting and full EBP implementation based on evaluations made by the interdisciplinary team. The last step in the Iowa model focuses on continued monitoring and analysis of the project outcome. With use of Iowa Model, one gains awareness on introducing, developing, and evaluating EBP from an evidence-based perspective (Brown, 2014).
Kotter's process of leading change offers an applicable change model for implementation in telehealth appointments. A process for leading change, Kotter's model is a credible and teachable process which clarifies potential misunderstandings that may create resistance (Reineck, 2007). Additionally, it provides guidance to leadership for planned changes (Smith, 2007). Implementation of telehealth is anticipated by the organization to mitigate patient barriers that lead to broken appointment rates, such as lack of transportation and new medical impairments from stroke. As the organization implements the use of telehealth, data is provided weekly at medical staff meetings regarding impact to access, patient satisfaction, and improved patient outcomes. Project change success will be shared and presented to other clinical specialties, such as those involving spinal cord injury and behavioral health. The practice change has been implemented and extended to other services and telehealth is now institutionalized.

Evidence Search Strategy
In support of the PICOT question, a search strategy used Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Dynamed Plus, and Cochrane Library from 2015 to 2020 to obtain high quality, evidence-based literature on the implementation of telehealth. Keywords and medical headings included stroke, cerebrovascular accident, adult patients, post stroke, readmission, nursing, and telemedicine. Controlled or feasibility trials included an intervention group receiving tele-rehabilitation for stroke survivors, compared with a control group on standard of care. The inclusion criteria were most of the keywords and articles published in the United States from years 2015-2020. The exclusion criteria included no reference in using telehealth, non-stroke population, application to home health or case management, and no reference to admission. Of 425 articles, only 29 non-duplicated citations were eligible based criteria set, English language, and title and abstract review. CINAHL showed 17 relevant articles, PubMed showed three relevant articles, Dynamed Plus had seven, and Cochrane Library had two relevant articles. After screening for full text review, ten studies fulfilled the predefined inclusion criteria based on (1) participation of nurse and other healthcare professionals, (2) application to stroke population, (3) impact of telehealth as an intervention, and (4) any impact or reference to stroke readmission.
Reviewed articles reported improved patient outcomes after integration of telehealth to their medical care outside of the hospital setting and reduction or avoidance of hospital readmissions ( Van den Berg, et al., 2016;Driessen, et al., 2016;Linder, et al., 2015). Studies utilized NPs in implementing telehealth for their patients and respective settings (Linder, et al, 2015;Collier, et al., 2015). Evidence based strategies were organized based on the outcomes of impact on readmission, and applicability of telehealth in the delivery of care among stroke patients.

Evidence Search Results and Evaluation
To gather scholarly work on EBPs supporting the implementation of telehealth For all the databases, the headings and keywords used were stroke, telehealth, rehabilitation, 30-day readmissions, nursing, and application to healthcare. To expand the search for supporting documents, other related articles were reviewed based on the references listed.
Inclusion criteria for all the databases and article search used most of the keywords, full text, English only, and years of publication in 2015-2020. The search resulted with citations as follows: CINAHL 17 citations, PubMed three citations, Dynamed Plus seven citations, and Cochrane Library two citations. Initially, the Journal search of NP did not match most of the keywords required to be useful in addressing the PICOT question. A total of 29 non-duplicated articles proved useful as references. All the 29 abstracts and titles were strategically reviewed and screened based on reference to stroke group, use of telehealth, and readmission.
After this initial review, nine articles were excluded based on the following: (1) absence of direct reference to use of telehealth, (2) population studied were cardiac patients with CHF, (3) application to case management and home health services, and (4) lack or no reference to readmissions. The remaining unduplicated twenty articles were reviewed as full text to determine the usefulness and relevance to the PICOT question. The result of search for research evidence yielded ten scholarly articles shown as a Prisma diagram (see Figure 1).

Figure 1: Results of Search for Research Evidence
Most articles referred to the use of telehealth intervention and referenced 30-day readmission. The EBP change project was supported by the articles selected that focused on the use of a telehealth intervention. Based on all the findings, the strength of recommendation was at level A on the Strength of Recommendation Taxonomy on consistent and good quality patientoriented evidence (Ebell et al., 2004).

Themes from the Evidence
A synthesis of the literature was appropriate to gain a better insight on the components of the PICOT question. This synthesis consisted of ten articles as follows: 7 qualitative (Bambhroliya, et al., 2018;Nouh, et al., 2017;Vahidy, et al., 2017;O'Connor, et al., 2016;Drissen, et al., 2016;Collier, et al., 2015;Strowd, Wise, & Umei, 2014) and 3 quantitative (Rosen, McCall, & Primack, 2017;Van den Berg, et al., 2016;Linder, Rosenfeldt, Bay, Sahu, & Wolf, 2015). These articles revealed major ideas for exploring telehealth as an innovative way to deliver healthcare and its impact in reducing 30-day readmission. A table of the summary of primary research evidence is provided (see Appendix A). The main themes identified in synthesizing these ten articles were (1) population, (2) application of telehealth, (3) impact on reducing 30-day readmission, and (4) role of a healthcare provider.

Population
The population identified for this study were patients with stroke who received follow up care after discharge. Two of the articles (Nouh, et al., 2017;Strowd, Wise, & Umei, 2014) recognized that patients with stroke experience a higher rate of readmission and strongly recommended that organizations focus on developing interventions to reduce readmission, such as early post-discharge follow up. Four descriptive articles (Rosen, McCall, & Primack, 2017;Drissen, et al., 2016;O'Connor, et al., 2016;Collier, et al., 2015) indicated the use of telehealth benefitted non-stroke patients in skilled nursing facilities, patients in palliative care, and patients with congestive heart failure, COPD, and diabetes.

Applicability of telehealth
The applicability of telehealth was a response to the innovation in healthcare to assist with the management of the aging population, rising healthcare costs, limited resources in rural communities, and specialized services such as palliative care and stroke care (Collier, et al., 2016;Van den Berg, et al., 2016). Two studies (Drissen, et al., 2016;Collier, et al., 2015) reported improved patient outcomes after integration of telehealth to their care plan outside of the hospital setting, particularly among patients in nursing home facilities and those under palliative care management. Patients who received telehealth interventions showed improvements in quality of life, depression, and mobility (Linder, et al., 2015). Incorporating a mediated telehealth exercise alleviated fatigue among caregivers of patients with chronic illnesses ( Van den Berg, et al., 2016;Shahrokhi, et al., 2018). Telestroke is a type of telehealth application used by a neurologist to remotely provide urgent assistance in diagnosing acute stroke (McSweeney, Pritt, Swearingen, & Kimble, 2017). This immediate intervention is crucial to save time and can dramatically improve the outcome of a stroke patient. (Wider, 2018).

Role of healthcare providers
Health care providers, such as NPs, proved instrumental in implementing telehealth and were an integral part of bridging gaps in health care delivery (Henderson, et al., 2014). Two of the studies (Linder, et al, 2015;Collier, et al, 2015) utilized NPs in implementing telehealth for their patients and respective settings. Telehealth was viewed as a change to some nursing roles that traditionally defined their scope of work as providing direct patient care (Segar, et al., 2013).
Telemedicine was not intended to replace direct patient care provided by healthcare professionals but augmented existing healthcare services (Segar, et al, 2013). Telehealth expanded provider's reach beyond their offices, allowing some to even work from home (Wider, 2018).
Evidence supported positive healthy outcomes for patients with stroke, particularly in reducing 30-day readmission rates (Kandola, et al, 2017). CMS (2020) updated an Evaluation and Management (E/M) service code 99441 for NPs and other health care professionals who performed telehealth phone visits to an established patient.

Practice Recommendations
The practice recommendations were based on a rigorous review of the literature from the evidence search strategy performed. The most important finding was that telehealth positively impacted patient outcomes, increased access, and simplified connectivity to the healthcare provider. The effectiveness of telehealth was based on findings consisting of self-reports based on focus groups, interviews, and surveys (Driessen, et al., 2016).
Telehealth also proved effective in redefining how services were rendered and improved the timeliness of appropriate care (Rosen, McCall, & Primack, 2017). Six of the studies indicated reduction in 30-day hospital admissions with the use of telehealth as a component in the transition of care (O'Connor, et al., 2016). Efforts to provide education regarding telehealth lead to clarity, acceptance, and early adaption to meet the rapidly changing healthcare delivery system (Segar, et al., 2013). Based on consistent findings in support of patient-oriented use of telehealth, the strength recommendation was considered at level 1 on the Strength of Recommendation Taxonomy (Ebell, et al., 2004). A logical intervention for the PICOT question was based on a summary statement drawn after considering all data in this synthesis and all other articles cited (see Figure 2).

Project Setting
Gathering a detailed assessment from the organization to determine the need for the intervention was an important contextual element. As part of the complex structure of a local Department of Health Services, the agency provided care to patients who were residents of Los Angeles. The organization has a service excellence in stroke management caring for over 2,000 patients with stroke aged 45 to 80 years old, including all genders from various ethnic backgrounds followed in its primary care clinics. Many of these patients were admitted from other hospitals for stroke rehabilitation due to deficits with mobility, speech, or cognition. Once discharged, they were followed in the outpatient stroke clinic.

Mission and Vision
The agency holds a unique position in the local health system by offering comprehensive rehabilitation needs and a robust outpatient clinic provides primary care service to this population with rehabilitation needs. The mission and vision are to provide high quality culturally sensitive patient centered care in a dynamic medical and rehabilitative environment.
With the organization's priority to innovate and transform care delivery, telehealth provides an opportunity for the organization to increase patient access to care outside the hospital setting.

Key Stakeholders
The key stakeholders for the EBP change were comprised of the Chief Information Officer (CIO), Chief Nursing Office, Outpatient Medical Director, and Nurse Informaticist.
Other stakeholders included the medical team in the inpatient stroke unit who set up telehealth phone clinic appointments prior to discharge. Stakeholders in the outpatient stroke unit were the patient care team for the stroke medical home team including medical providers, clerical support, and all levels of nursing. The most important stakeholders were recent stroke patients offered this service and in need of post discharge follow-up, experiencing impaired mobility from stroke, difficulty accessing transportation, or lacking familial support to get to a clinic appointment.

Organizational Assessment and SWOT Analysis
Three organizational assessment tools were used to determine organizational readiness for practice change and planning for the quality improvement project on telehealth clinic visits.
The tools consisted of the IHI improvement Capability Self-Assessment tool (IHI, n.d.), the checklist that assessed organizational readiness (CARI) for evidence-informed practice (Barwickj, 2011), and the IHI Organizational and Informational Readiness checklist for integrated finance and safety (IHI, n.d.). In synthesizing these tools, the executive leadership was exemplary and ready to support implementation of telehealth in the outpatient clinic. The tools were consistent in identifying an area that needed attention where multidisciplinary collaboration and training was needed related to telehealth.
A SWOT analysis of the agency was performed to identify its strengths, weaknesses, opportunities, and threats (see Appendix B). Some of the strengths identified were strong leadership support, the agency's pursuit towards innovation, and the enthusiasm by the interdisciplinary team to use telehealth. Some of the weaknesses identified were telehealth use as new technology and new information, competing priorities, and staff resistance to change.
Opportunities included utilizing existing implemented telehealth in the Department of Health Services, identifying the equipment to be used for telehealth, and interdisciplinary training and collaboration. The threats identified were patient's preference for face-to-face (F2F) appointments, their lack of access to a phone, regulatory requirements with telehealth, and impact to reimbursement.

Project Overview
The intended outcome of the project was to determine if a reduction in readmission rates below 14% occurred among patients who had a stroke within 30-days of discharge and within two months after implementing telehealth clinic appointments. The mission and vision of the project was to provide patient centered care in a dynamic rehabilitation environment. This aligned with a strategic priority of the agency and its mission and vision to provide restoration of health and hope with a focus on delivering patient and family-centered care. It was also reflected in the strategic goal to provide the right care at the right time and the right place (Rancho, n.d.).
The short-term goal of the project was to implement the new workflow for telehealth phone visits and maintain consistency with using the protocol. The long-term goal was to expand application of telehealth by reducing the amount of readmission among patients with strokes.

Unintended Risk and Consequences
The project's unintended risks and consequences revolved around technology with connectivity issues and patient confidentiality. Mitigating these risks involved key stakeholders regarding devices and the implementation of a downtime procedure when delays in connectivity occurred. Regular checks of the equipment were performed to establish functionality during telehealth visits. The team members completed the Health Insurance Portability and Accountability Act (HIPAA) training and involved the CIO to mitigate risks on patients confidentially and breach of information. Telehealth policies were developed to capture patient's consent for telehealth. Other unintended consequences or risks associated with the project was resistance to integrating telehealth into standard practice, limitation of office space and furniture, patient's preference for standard-of-care with clinic appointments, and constraints imposed by organizational policy and other regulatory standards on telehealth. An ongoing risk assessment for the telehealth project was conducted to raise awareness for potential risks and consequences.

Project Plan (Method)
The planned project of implementing a telehealth appointment to follow-up stroke patients post-discharge was a systematic project to improve the current process on how care was delivered to the target population (Nelson & Staggers, 2017). In support of the PICOT question, the project planned to compare patients who received telehealth phone visits to those patients who received standard face-to-face discharge follow up appointments and determine the impact on 30-day readmission rate during the study period. The goal was to reduce readmission rates to less than 14% by developing a process to implement telehealth phone visit. A process was developed on how to implement a telehealth phone visit, identified tools for patient recruitment, trained and educated the patient care team, including NPs, and evaluated the outcome. Early collaboration with the facility informatics team confirmed capabilities to provide telehealth services. The current process was refined, which included developing a specific electronic progress note for phone visits referred to as "Outpatient Phone Visit Note" for consistency of documentation. A flyer was distributed to patient care team as an invitation to convey the EBP change project. Attendance and completion of training by staff was tracked through a sign-in record (see Appendix C). The primary audiences selected for the training and orientation were given an in-service utilizing a power point presentation by the project manager regarding background of the project change proposal and implementation of telehealth phone visit within the organization (see Appendix D). The objectives of the presentation were to introduce the concept of telehealth phone visits, discuss its implication to nursing practice, identify the chosen population, and address new workflow on setting up an appointment and documenting a telehealth phone visit using a specific phone visit note type. The importance of implementing an EBP change with telehealth phone visit promoting access to care and mitigating potential 30-day readmission was stressed. The project manager also supplemented the participant's learning with a handout on how to conduct a telehealth phone visit and showed step-by-step where to find information in the EHR (see Appendix E). The job aid provided clarity to staff regarding their roles as a care team throughout the phone visit. A template for a phone visit progress note was developed to capture key elements to document including how to designate an evaluation and management (E/M) code that reflected clinical services provided to the patient and the duration of the phone visit encounter. The NP was trained to perform telehealth phone visits including the importance of accuracy in electronic documentation using the new "Outpatient phone visit note type" (see Appendix F).

Iowa Model for Evidence-based Practice
With the implementation of telehealth phone visits with the NP, the Iowa Model was used successfully to implement a practice change in the outpatient setting. Using the step-by-step approach of the Iowa model resulted in consolidation of leading evidence from research studies, clinician's competence, and patient's choice (Melnyk & Fineout-Overholt, 2015).
The model began with identifying a problem-focused trigger, such as stroke readmission rate. The organization provides primary care services to 3,000 patients with a stroke. In comparison to the national readmission data, the local health care system has an 18% readmission rate for patients with stroke (Rancho, n.d.).
The second step was to acknowledge if this was a priority for the organization. Based on data of the local Department Health Services on stroke readmission rate, the facility found an opportunity to reduce the current readmission rate. Both leadership and key stakeholders identified the impact of a practice change, such as providing telehealth phone visits to mitigate this problem. Telehealth phone visits were rendered to patients as a discharge follow-up strategy that impacted reduction of hospital readmission among this population. Using telehealth phone visits for follow-up care helped improve services to patients, improved health care outcomes, and  Driessen, et al., 2016;Linder et al., 2015). Additional studies supported the use of NPs in implementing telehealth for their patients (Linder, et al, 2015;Collier, et al., 2015).
The fifth step was a pilot implementation of the new telehealth phone visit protocol. As part of discharge planning from the inpatient unit, the patient was offered a telehealth phone visit with the NP within two weeks of being discharged from the hospital instead of the standard practice of a face-to-face clinic appointment. The project team provided training and orientation on the change project and implementation of telehealth using the guideline on how to conduct a phone visit (see Appendix G). Patients were informed a telehealth phone visit was available using a patient information sheet provided to them (see Appendix H). A copy of this signed information sheet was placed in the patient's health record. Appointment reminder phone calls proved effective in reducing no-show rates in the outpatient care setting (Shah, et al., 2016). The CMA called the patient two days prior to the clinic appointment. The NP was allotted 40 minutes to complete a telehealth phone visit encounter with the patient.
The last step was to evaluate the impact of the practice change on stroke readmission rates. Data was monitored at 7 days, 30 days, and 60 days to determine 30-days post-discharge readmission rate among patients who received telehealth phone visit. A review of participants at 30 days to meet the 60-day timeframe for implementation was conducted. Information on patient outcomes and patient experiences were presented during monthly management meetings. A project timeline was provided (see Appendix I). By performing a chart review and generating a report from the facility's repository on admissions associated ICD-10 for stroke, readmission rates were determined among this target population. Two days after the phone visit appointment, the CMA contacted the patient by phone and completed a 12-question survey on the patient's experience with telehealth.

Kotter's Model of change
Applying Kotter's model of change aligned with the organization's process in providing clarification to potential misunderstandings that created resistance to change. There are three key components for Kotter's model of change: (1) initiate or create the climate for change, (2) implement or engage and enable the organization, and (3) institute or implement and sustain change (Kotter, 1995). Under the first component, the organization embraced telehealth as a growing concept, the project champions were identified, literature review was performed, and a project proposal was developed pertaining to changing face-to-face appointments to telehealth.
Under the second component, telehealth was offered to patients with a recent stroke.
Information Technology (IT) support prepared clinic appointment schedules and developed electronic health records. The project team set up launch dates and began staff training. One key metric for success was the reduction of 30-day readmission rates. Under the third component, data was reported using a dashboard and monthly reporting to the management team was scheduled highlighting the impact on patient outcomes satisfaction. The integration of practice change began in orientation and training with the core patient care team selected for the project.
By spreading the word regarding telehealth, other services benefitted from this modality in managing their patients. Patients with stroke were scheduled a telehealth phone visit with the NP two weeks after discharge. The discharge nurse educated the patients regarding discharge follow up through telehealth in the outpatient setting.

Interprofessional Team Collaboration
The team members involved in the project implementation were the appointment schedulers, the RNs, the NPs, and the CMAs. The stakeholders for the EBP change were the patient care team in the inpatient stroke unit because they set up phone telehealth clinic appointments prior to discharge. In the outpatient setting, the stakeholders were the patient care team for the stroke medical home team.

Project Budget
A budget outlined an estimated total cost of the project and guided the care team in controlling cost (Neil & Swig, 2017). In studying the budget related to the project, there were projected direct and indirect costs involving personnel salaries and benefits, training costs, equipment and supplies, and office space allocated for telehealth. The budget was minimal as the costs to the current infrastructure to support telehealth, such as computers, phones, and office space did not change. There was no additional staffing needed for this study. However, it was valuable to be keen on potential incurred costs to sustain the project, such as budgeting towards IT support and additional computer stations (see Table 1).

Barriers
There were a few identified barriers to success. The first was the uncertainty with the payment model or reimbursement for telehealth services. There was a lack of IT support and connectivity infrastructure. A barrier with patient's deficit in knowledge and awareness of telehealth impacted their engagement and willingness to participate with telehealth. To promote telehealth, the agency considered incentivizing enrollment by providing transportation for the next F2F appointment when necessary. Despite these barriers, the project was supported by key stakeholders, who worked collaboratively to ensure that minimal to no barriers for the implementation of the project arose. Administrative support was received from leadership in completing policy and procedural guidelines, identifying nursing support and training, securing office space for telehealth, and identifying NPs. The nurse informaticist performed data gathering and collection, worked with the project manager on data reporting, and coordinated the nursing care team for follow up on the use and adherence to protocols.

Role of the DNP Student
The

The USAHS Evidence Based Review Council and the facility's Evidence-based Practice
Council (EBPC) approved implementation of this project. Program evaluation was performed, and results were based on data collected to measure the effectiveness of the telehealth phone visit in reducing 30-day readmission rates among stroke patients. Patients, 18 years of age or older with a recent diagnosis of stroke of less than six months being discharged from a local county hospital, were eligible for a telehealth phone visit with a NP. Admissions and discharges were tracked with the Department of Health Services' discharge database based on admission with an associated diagnosis of stroke. The data collected on population included age, gender, comorbidities, and stroke diagnosis. Event data included discharge date, telehealth appointment date, and completion of telehealth visit. Outcome data was based on days since previous admission.
Data was collected from the patient's EHR and discharge databases at seven and 30 days for all participants to capture readmission rates. Evaluation tools captured nominal and numerical data and included analysis on process and outcome measures (see Appendix J). Data was collected and stored on SharePoint and an Excel sheet secured by a password login created by the DNP student. Integrity of the data collection process was ensured by using securely accessed EHRs, chart review for a completed telehealth visit using an audit tool and following standardized ICD-10 codes for identifying admissions with stroke-related diagnosis (see Appendix K). All patient care team members were familiar with the workflow and the inclusion and exclusion criteria and ongoing surveillance of data collection minimized missing data.
Patient identifying information was removed from the data collection to follow HIPAA protocols. An unpaired t-test was used to report percentages of the variables to show differences among discharged patients who received a telehealth or in-person appointment. To assess patient experience, a 12-question telehealth survey was developed guided by evidence-based search and completed by the patients (see Appendix L).
Data collection occurred in the project implementation period of October 13, 2020 to November 13, 2020. During the reporting period, the stroke unit discharged a total of 46 patients.
All were offered a telehealth phone visit as their follow-up appointment. Only 37 patients consented to use telehealth and were scheduled appointments. This translated to 80% of all total stroke discharges consented to participate in a telehealth appointment but only 32 patients completed a phone visit.
Participants of the study included adult patients discharged from the hospital with a diagnosis of stroke. The demographics of the participants are described in Table 2.

Table 2: Characteristics of Patients who Received Telehealth
Out of 32 participants, two readmissions within 30 days from discharge occurred (see Table 3). One patient experienced urinary retention and the other abdominal pain. The average F2F clinic visit follow-up for patients after their initial post-discharge appointment occurred between 8 to 12 weeks later and found that stroke patients were seen for F2F appointments after participating in telehealth appointments an average of 9 weeks after their initial telehealth phone visit (see Table 4). This is comparable to the length of time when a patient would be routinely followed-up. All identified project team members were educated on the workflow on enrolling patients prior to discharge with telehealth phone visit appointments. Stroke patients are seen on an average of three times annually. Each visit costs $20.00 for general transportation to a clinic appointment. Because these patients participated by phone, the potential cost-saving toward transportation was $60.00 annually to the patient. This is particularly meaningful for the 11 participants (34%) without any payer source.
In using descriptive analysis, provider and patient self-report were included on the use of telehealth. Based on the feedback received from the NPs during team meetings, the provider expressed satisfaction with their experiences using telehealth compared to F2F appointments.
The provider noted positive interactions with patients due to convenience, ease of use, increased access to care, and embraced their roles with transforming how care was delivered to patients.
Patients received a patient experience survey two to three days after their telehealth phone visit. Out of the 32 participants, only 25 patients responded, making the response rate 78%. Nearly 84% of the responders reported they agreed (value of 3) or strongly agreed (value of 4) with a positive experience using telehealth. Patients' direct quotes written on surveys were a mixture of both positive, negative, or neutral comments based on their experiences during the telehealth visits (see Table 5).
Based on the reported findings from the EBP change project, there was clinical significance with telehealth as an option for stroke patients who received their post-discharge follow up care. The EPB project change met the goal based on data presented, which suggests telehealth was an effective intervention for reducing 30-day readmission rate among patients with stroke. Other data results, such as the patient satisfaction survey, provider feedback, timely access to phone visit appointments, and length of phone visits, showed that both quality of care and efficiency were not compromised by the telehealth phone visits.

Impact
The implementation of telehealth phone visits by NPs reduced readmission rates among patients with stroke. Adoption of this practice has positively impacted healthcare by providing an alternative for patients on how they want to receive follow up care after hospitalization. This project resulted in access to care within ten days of discharge, reduced broken appointment rates, and lowered readmission rates. The efficiency of a telehealth phone visit is comparable to a F2F appointment. Based on self-reports by the participants, patients responded positively to the convenience of telehealth and displayed a preference to receiving telehealth phone visits over F2F visits for their post-discharge follow up.
The successful completion of the EBP practice change provided guidance on successful execution of telehealth phone visits, which can easily be replicated by utilizing developed workflows, processes, training modules, and evaluation tools. To further improve the practice problem, data collection period was extended to permit a larger sample size and expand the participants to non-stroke patients. The program continued tracking efficacy through monthly data reporting and analysis of patient survey results. In addition, stakeholder engagement and staff training were crucial strategies for sustainability.
The impact of this project is limited by the dependence on access to technology. If the patient did not have access to a computer, a smart phone or other devices that would allow for telehealth visit, then the patient had to opt for a F2F appointment. If this project is to be replicated, overall time spent during an F2F clinic visit (from check-in to discharge) versus a telehealth clinic time with the NP should be reviewed. The potential time saved can be converted into additional appointment slots for the provider, as this information is lacking from the EBP project change regarding the increase in the number of patients who can be seen through telehealth visits.

Plans for Dissemination
The result of this project will be communicated using a PowerPoint presentation within the organization at a one-hour town hall meeting in a reserved auditorium. A flyer and invitation will be emailed to relevant participants and a poster displayed in the outpatient clinic for staff to view will encourage discussion and interest. Allowing the NPs who utilized and incorporated telehealth into their clinical practice to share their experience at the presentation and transfer knowledge encourages others to transform their own processes in their respective organizations promoting sustainability of the project change.
Regional dissemination of the project results may benefit adjacent counties who render specialty and rehabilitation care. The five other county facilities within the vast health care department will receive the project results through the monthly DHS meeting attended by interprofessional team members.  Research Tools Used: Stroke Impact Scale mobility domain and for Data Analysis a descriptive statistic was used to examine the data; using intention-to-treat principle; intervention was tested using linear mixed models which are group, time, and group x time and baseline scores.

Chronic disease Management
An 8-week program of CME and e-health support will have improved mobility, reduce hospital stay, and reduce burden to caregivers. CME supported by telerehabilitation augments intensity of practice, resulted in improved ADL, reduces hospital days with fewer readmissions post stroke and reduced levels of caregiver fatigue The findings from the study justifies a larger randomized controlled trial in a multicenter to evaluate the effectiveness and cost-effectiveness of the intervention and indirect cost savings from preventing readmissions.
Recommends future studies in other post-discharge settings such as nursing homes and its applicability of CME to patients with brain injury.

Chronic care Model
The IVR method to increase communication between postdischarge patients and clinicians did not improve overall 30-day readmission rates. The readmission rates were roughly the same between the intervention and control group.
IVRs are not effective in reducing 30-day readmission. This could be due to IVRs being informal and low investment. Patients are not getting proper guidance from IVRs to maintain self-care regimens after discharge.