The Virginia Department of Health (VDH) is the Code-mandated agency responsible for stroke care improvement initiatives within the Commonwealth. Per Virginia Code § 32.1-111.15:1, VDH is tasked with overseeing four primary stroke care initiatives:

1. Implementing systems to collect data and information about stroke care in the Commonwealth

2. Facilitating information and data sharing and collaboration among hospitals and health care providers to improve the quality of stroke care in the Commonwealth

3. Applying evidence-based treatment guidelines for transitioning patients to community-based follow-up care following acute treatment for stroke

4. Establishing a process for continuous quality improvement for the delivery of stroke care by the statewide system for stroke response and treatment

VDH is required to provide an annual report to the Governor and General Assembly on stroke care improvement initiatives undertaken in accordance with this Code section, and to include a summary report of the data collected pursuant to this section. This report serves to fulfill this requirement for 2024.

RECOMMENDATIONS

Virginia Code § 32.1-111.15:1 (3)(C) requires VDH to develop recommendations for the improvement of stroke care throughout the Commonwealth, and Chapter 198 of the 2018 Acts of Assembly requires VDH to convene the VSCQI to advise on the implementation of the provisions of § 32.1-111.15:1. Pursuant to these requirements, the VSCQI worked in partnership with VDH to develop the following recommendations for improving stroke care initiatives in the Commonwealth, which are based upon the four primary stroke care initiatives as listed in Virginia Code § 32.1-111.15:1:

Implement Systems to Collect Data and Information about Stroke Care

1. Non-certified stroke centers, as well as free-standing emergency departments and post-acute discharge facilities, such as inpatient rehabilitation facilities and skilled nursing facilities, should contribute data to the Virginia Stroke Registry. VDH is currently establishing the Virginia Stroke Registry to serve as the statewide system for collecting data and information on stroke care in the Commonwealth, as required by Virginia Code § 32.1-111.15:1.

2. The Virginia Stroke Registry should collect additional data elements related to specific populations of interest, including pregnancy status and sickle cell status. The Registry should also collect data elements regarding patients who have been treated using advanced stroke therapies.

3. The Virginia Stroke Registry should include the collection of “Z" codes (ICD-10 codes for social determinants of health) in order to address disparities of care across Virginia.

4. The Virginia Stroke Registry should serve as a resource to hospitals and free-standing emergency departments to implement quality improvement efforts, including ongoing stroke certification processes.

5. The Virginia Stroke Registry should be interoperable with additional Virginia data sources, such as the Virginia Vital Events Statistics Program, to comprehensively describe stroke burden and gaps in stroke care along the full continuum of care.

6. Currently, there is no dedicated funding (General Funds or grant funds) for VDH to develop and sustain the Virginia Stroke Registry. The General Assembly should appropriate $700,000 in general funds annually to cover the necessary costs of staffing and Virginia Stroke Registry infrastructure to fulfill the requirements mandated in Virginia Code § 32.1-111.15:1. The $700,000 represents the previously quoted cost of software maintenance ($107,000), the Stroke Registry data quality assurance platform ($135,000), the EMS and hospital data integration to support data modernization and data quality ($50,000), and the funding of three full-time staff to facilitate and maintain the stroke registry ($408,000). The three full-time staff are comprised of the Stroke Registry Coordinator, Epidemiologist senior, and Epidemiologist mid-level. The General Assembly has not previously contributed funding to support the development and/or maintenance of the stroke registry or staff funding; the mandate is unfunded.

Facilitate Data Sharing and Collaboration

7. The Virginia Hospital and Healthcare Association (VHHA) Collaborative should continue to engage the non-certified stroke hospitals and guide them towards stroke certification, participation in the Virginia Stroke Registry, and quality improvement.

8. The American Heart Association’s (AHA) Get With The Guidelines ®-Stroke participating hospitals should activate the Coverdell layer, a nationally recognized data set, to submit to Phase 1 of the Virginia Stroke Registry. This means that those hospitals would be extracting additional data from patient records and submitting that data to the Registry, following AHA’s national best practices for the kind of data hospitals should collect and report on stroke incidences.

9. VDH should continue to work on development of Phase 2 of the Virginia Stroke Registry, to better enable data sharing and collaboration.

Apply Guidelines for Transitioning Patients to Community-Based Follow-Up Care

10. Hospitals should continue to use Unite Us, or any statewide referral platform, to alleviate the burden on hospital stroke coordinators and care managers of connecting patients to necessary services post-discharge.

11. The General Assembly should appropriate $5.5M in general funds annually to sustain the statewide e-referral system (Unite Virginia) for hospitals and community-based organizations, with consideration of Community Health Workers as frontline public health workers at the core of the referral system. $5.5M represents the current annual cost of Unite Virginia, which VDH is currently using CDC grants to support. The General Assembly has previously contributed funding to support the e-referral system, but the latest biennial budget does not include any funding for this work.

Establish a Process for Continuous Quality Improvement

12. VDH should continue to release the VDH Hospital Stroke Inventory Survey annually to all stroke hospitals, and update questions year to year to reflect current trends and process improvement outcomes for stroke care.

13. VDH should continue to collect data in conjunction with the Office of Emergency Medical Services (OEMS) resulting from quality improvement projects related to pre-hospital patient care.

14. VDH OEMS, in collaboration with the VDH Office of Family Health Services (OFHS), should continue the process of updating the Emergency Medical Service (EMS) State Stroke Triage Plan to improve notification processes between EMS and the hospitals to better support eligible patients in receiving advanced treatments for stroke.

15. VDH should investigate why EMS agencies are transporting suspected stroke patients to non-certified stroke centers or out of state facilities, as opposed to in state stroke-certified facilities.