The Power of Three: Collaboration Can Help Stroke Survivors Return to Independence

Editor’s note: The SCAN Foundation, The John A. Hartford Foundation, the Administration for Community Living, the Gary and Mary West Foundation, the Marin Community Foundation and the Colorado Health Foundation have united to fund a three-year grant to develop and establish the Aging and Disability Business Institute, housed within n4a. Under the grant, ASA and n4a ( are collaborating on a series of articles and case studies in Aging Today that will help to prepare, educate and support community-based organizations and healthcare payers to provide quality care and services.
Mortality from stroke has decreased substantially in the past two decades, but acute ischemic stroke hospitalization rates have increased, as have stroke risk factors and the prevalence of people who have three to five risk factors. This is an alarming trend, but three agencies in Colorado—the Colorado Visiting Nurse Association (CVNA), East­er­seals Colorado and Project Angel Heart—hope to collaborate to help stroke survivors. The agencies see an opportunity to sup­port these individuals by accelerating their return to independence following a hospital stay.
The CVNA provides preventive wellness health services such as immunizations, nursing, physi­cal and occupational therapy, hospice and palliative care, and paraprofessional services like house­keeping. CEO Christopher Lee says, “Our key mission is helping people age and heal in the home.”
Easterseals Colorado’s mission is to help people with disabilities and their family members to remain as independent as possible through myriad services, meeting daytime needs of children, adults and older adults, as well as providing respite for their caregivers.
The third agency, Project Angel Heart, prepares and delivers customized meals to people living with chronic or life-threatening illness.
These agencies are in talks with a national healthcare system to develop and pilot a new stroke care model that will allow stroke survivors to smoothly transition from hospital to home without experiencing the typical patient stay in a rehabilitation facility. The model will involve a complex web of services, not all provided simultaneously, with some services offered repeatedly over the course of months.
Agencies Unite Their Strengths and Missions
The CVNA combines acute, short-term home health services that begin within 12 to 24 hours of hospital discharge after a stroke, which will be combined with Easterseals’ stroke day program, plus Project Angel Heart’s meals, as a way to “get people home sooner at lower cost and with higher satisfaction,” Lee says.
“The goal is to get the stroke survivor into Easterseals’ program as soon as they are able,” says Lee. “[The] CVNA provides the nursing, physical and occupational therapy, and speech therapy, until that happens. We provide the medical oversight and support at home so [stroke survivors] can continue get­ting better.”
“People often don’t go home [from the hospital] because they can’t spend four to six hours home alone, but with Chris’s group getting them stable, helping to train the caregiver to learn the medical side of [the patient’s] care and participating in initial stroke ther­apies right away, then they can come to Easterseals’ day program,” says Lynn Robinson, Easterseals Colorado presi­dent and CEO.
Easterseals offers a five-day-a-week stroke program with physical, occupa­tional, speech and cognitive therapies, and warm water therapy exercise. “Stroke survivors regain skills, and learn how to accommodate their disability and overcome challenges. In a hospital or long-term-care facility one might get an hour or two per day of therapy, over four to six weeks, but in our setting they are here for six hours a day, and they’ll get one or more of the modalities they may need,” says Robinson.
An added benefit comes from the other stroke survivors in the Easterseals program: partici­pants encourage and cheer each other on in a social environment that helps them to overcome the accompanying depression that commonly follows major traumatic events.
Connections Made Through Linkage Lab
The CVNA and Easterseals in 2015 received grants from the Colorado Health Foundation to par­ticipate in its 18-month long Linkage Lab, where they were encouraged to create a pilot in the healthcare sphere.
“As we were trying to create partnerships with hospitals, it struck us that [CVNA and Eas­terseals] were doing similar things. CVNA was trying to keep people in the home, and Easterseals had this other place …  that helps people get support. [The partnership] seem[ed] like a natural evolution,” says Lee.
“We both thought that with a bit of overlap it was more likely we could wrap around an indi­vidual with multiple services, so they weren’t struggling to find each piece. We would come to them with a one-stop shop, and it would give the hospital a way to refer patients so they’re not … without support,” says Robinson.
Pilot participants will be connected with their primary care physician, assisted with medication compliance and other issues, such as diet, that can put them at risk for another stroke. Stroke re­covery involves a long learning process requiring substantial training, to which both agencies can contribute. “We [plan to] help patients and their families to keep moving toward a healthier exis­tence,” Robinson says.
Addressing the increase in stroke incidence, Lee said there are definitely more patients spending more days in skilled rehab and more days in hospitals, neither of which is always necessary. The part­nership’s web of services would be less expensive for families, patients and providers: “It’s similar to the whole idea of PACE, without the investment in facilities, doctors, etc.—a cheaper way to provide care,” says Lee.
Both agencies have devoted much time and thought to the pilot program and are working with the healthcare partner to gain support for the pilot. “Part of the process is getting the volume [of people served] at a higher level so that we can afford to [provide services] at the rate we’re doing it and [hopefully] there’s a cost-savings for payers,” says Robinson.
If the agencies’ collaboration can serve to cut down—if not eliminate—patients’ time spent in rehab, it still would translate to considerable cost-savings.
Reducing Readmissions
Despite the complexity of this arrangement, Lee says, “I like to think of it as simple. We each come in at different times. CVNA and Easterseals can fade in and out of the picture, as the person’s needs change. If the person has a new condition, and needs to leave the day program and return home, they can re-engage with CVNA … and come back to Easterseals as soon as they are healthy enough.”
Robinson agrees. “Once Chris’s team can get a person to a stable point, they come into Eas­terseals, where we have a ton of social support. Sometimes people just vent about issues and some­times we’re problem-solving.
“Project Angel Heart brings meals into the home, which is more socialization, and the [meal deliv­ery drivers] are another set of eyes in the patient home if any concerns need to be reported back,” Robinson adds. Often, people recovering from stroke are distracted, exhausted, unable to prepare proper food and do not know the best foods to eat, given their condition. Having medically tailored meals prepared for 30 to 90 days helps reduce these patients’ risk of hospital readmission.
“If you look at the reasons people readmit, there’s a significant incidence of people readmitting because they’re not eating in a way that [supports] them, either not [eating] the right food, or they’re unable to get the food,” says Lee.
“We have a common interest here. We’re [all] trying to find a way around or through the issue of getting people out of rehab centers and being dropped [home with no support]. Instead they’ll be in a place where they have support in the community, and could even get back to work,” says Robinson.
Although still at the beginning of their partnership process, these three agencies seem confi­dent they will pull off the pilot. “There will be bumps,” says Lee, “maybe once we start figuring out fees, some … things [will] get challenging. But we’re willing to [find] ways that might be a financial win for everyone.” 
Editor’s Note: This article appears in the January/February 2018 issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.