The Neurologist Is In, Episode 2: Teaming Up in the Stroke Unit and Beyond With Dr Mona Bahouth and Dr Deborah Dang

In episode 2, Rachel Marie E. Salas, MD, interviews Mona Bahouth, MD, PhD, and Deborah Dang, PhD, RN, about the Johns Hopkins TeamingUP Model©, an interprofessional, patient-centered model currently being studied in the Johns Hopkins Hospital Brain Rescue Unit. A full transcript is provided below.

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About the Speakers:

Rachel Salas, MD, MEd, is an associate professor of Neurology and Nursing; director of Interprofessional Education and Interprofessional Collaborative Practice; director of the Neurology Clerkship; and 2019-2021 Josiah Macy Jr. Faculty Scholar at Johns Hopkins University in Baltimore, Maryland.

Mona Bahouth, MD, PhD, is the medical director of the Brain Rescue Unit, and assistant professor of neurology at Johns Hopkins School of Medicine in Baltimore, MD.

Deborah Dang, PhD, RN, NEA, BC, is the director of Nursing Practice, Education, and Research at Johns Hopkins Hospital in Baltimore, MD.

Read the Transcript:

Dr Rachel Salas: Welcome back, everyone. I am Dr Rachel Salas. I'm a sleep neurologist at Johns Hopkins. With me today, I have 2 fabulous guests.

I have Dr Debbie Dang, who's here and is going to be talking to us about interprofessional rounding. I'm not going to steal her thunder—I'll let her talk a little bit more about her work in a second, after a formal introduction.

I also have Dr. Mona Bahouth who is doing some amazing work, not only clinically, but in her research as well. With that, why don't we get started? Dr Dang, do you mind giving the audience a little bit of your background?

Dr Deborah Dang: Sure. Thank you, Rachel. I'm glad for the opportunity. I have worked at Johns Hopkins Hospital for a number of years. The role that I had there was focused on improving the practice environment for nurses and other staff, particularly around bringing meaning to their work. During that time there, I worked on developing professional practice model, salary compensation, clinical advancement programs.

More recently, I became the chief nursing director for well-being and the senior director of nursing research for the Johns Hopkins Health System, which is a 6-hospital system. In that role, my focus was really to look at research and to look at innovations for creating well-being among interprofessional clinicians at the bedside.

Dr Salas: Great. Thanks, Debbie. Dr Bahouth, do you mind telling our audience a little bit about yourself and your career path?

Dr Mona Bahouth: Hey everyone. My name is Mona Bahouth. I'm a stroke neurologist at the Johns Hopkins Hospital and the medical director for our Brain Rescue Unit, which is our stroke unit in the hospital.

My professional quest has, for a long-standing, been to really improve the life of every single stroke patient. The only way to do that is through a team approach to patient care.

While I'm a stroke neurologist now, my role started at the bedside as a neuroscience nurse in the intensive care unit in upstate New York, a much snowier place. There I became very intrigued with the brain, the function of the brain, and how the brain really recovered when things were not going right.

Whenever there was pathology that interfered with the brain's ability to function well, I became intrigued with understanding why that's happening and how we can help patients and their care partners to improve. I really enjoyed my time at the bedside. I feel like I've never left ever since keeping my work very patient-centered and patient-focused since that time.

In the stroke unit, we work on a lot of innovative approaches to system care and to developing the most cutting edge systems that we can for every single stroke patient from the point of technology integration, as well as staff integration and program development along the continuum of care. I'm really pleased to be here today. Thanks for the invitation.

Dr Salas: Thanks to both of you for taking the time. I know we're upon the holidays for sure. Taking that time is very important to us. Why don't we get started?

Debbie, I'd like you to share with the audience a little bit about SIBR—what that is, maybe why it's important, and why we should all be thinking about this model moving forward.

Dr Dang: I'm really excited about this innovation that we're actually doing a study on at Johns Hopkins. Just a little bit of a background for framing: Back in 2012, there was a collaboration of many organizations that were brought together to develop collaborative practice competencies.

The reason that they did that was because there was an IOM study in 2003 that identified interprofessional collaborative practice as a core competency for clinicians in health care. The focus of SIBR is really about creating an environment and a structure that makes it easy for clinicians to practice collaboratively.

Ultimately, patients are the justification for this collaborative practice. There's been an increase interest in team-based care and how that contributes to the quality of work life. SIBR stands for structured interprofessional bedside rounds.

At Johns Hopkins, our study is focused on implementing an adaptation of that titled, "The Johns Hopkins TeamingUP Model." SIBR is a model primarily for inpatient care. It's focused on a daily rounding process that occurs at the bedside with the standard number of professionals to discuss the plan of care for patients and their families for that particular day.

By doing so, patient and family members actually become members of the rounding team. This structure is consistent. I think the most important thing about it is that it is designed by the clinical care team on their unit. It can be adapted and is adapted depending on the unit.

I think it's important because they know their workflows the best. Their focus is really taking 6 standardized components and really customizing how it might work on a stroke unit vs a congestive heart failure unit vs labor and delivery. We all know culture is local so that's a really important part of it.

The role of the research team in this model is really to support, guide, and coach, and provide data back to the unit-based team so they can make adjustments on a daily basis. There is a growing body of evidence about this in the literature. There are many positive outcomes for why we might want to do this on inpatient units on more large-scale basis.

This is a new area of research, and there is a growing body of evidence that shows that using a structured format for daily bedside rounds improves teamwork, patient care, and safety. It also improves clinical processes and most importantly for the health care team, it does improve efficiency, because the current rounding process, which is really a teaching model, can be very time-consuming.

Although the teaching model for rounding is not eliminated, it shifts its focus away from that direct patient intervention, and that part of it is really created through the SIBR interprofessional bedside rounds.

Dr Salas: That's interesting, Debbie. I think that's important to point out that, because I think when people hear something that has, especially an acronym like SIBR, right, that it's just a checklist, and that it's standardized across all units, all teams, and it's just you go, "1, 2, 3, 4, 5." That's actually not the case.

This is somewhat of a standardized process and there are some key things to hit, but it's really up to the team, and we'll hear a little more about that from Mona in a second. It's really about the team customizing it to who they are as a team, who's on their team, and who their patients are, and what their needs are.

Let me transition to Mona. I'd like to hear, Mona, just before getting involved with Debbie and her study team—do you mind telling us a little bit about your unit? Who's on the unit? What kind of patients do you take care of? What's the whole goal of the unit and your mission as a team?

Dr Bahouth: When Dr Dang and Dr Salas came to us and said SIBR might be for the stroke unit, I felt like it was actually a perfect marriage. The stroke unit, generally, is a place where you have a high degree of contact with interprofessional activity to both coordinate care and deliver therapeutic care to stroke patients.

The stroke unit itself is a place embedded in the neuroscience unit. It is a 12-bed, intermediate care unit where stroke patients come from minute 1 of their strokes, periodically, and can stay for several days, or even weeks, depending on the complexity of their stroke. There, they receive the expertise of neuroscience nurses who are really the core to the delivery of care for stroke.

Because clinical and neurologic monitoring takes place in those first minutes, hours, and days, assessment and complications are really critical to show patient success. You also have the expertise of stroke neurologists, advance practice nurses, and multiple levels of therapists.

Most recently, we enhanced our therapy model to change from really a system that would only evaluate stroke patients for their next destination and care really to figure out where the stroke patient should go to begin their recovery care, to really embedding recovery care right into the stroke unit.

On a given day, a stroke patient will need the entire care team. There will be typical rounds that this audience is very familiar with, with a stroke neurologist and the team leading patient rounds, interaction with the patient assessments, many diagnostic tests. Also, the patient will receive 2 to 3 hours of therapy per day on that unit with a variety of therapists.

On each given day, the patient may see a physical therapist, occupational therapist, and speech and language pathologists to improve their recovery function from day 1. We've transitioned from an hyper-acute unit to a recovery unit as well. Of course, the audience is very familiar with all the hyper-acute therapies that are delivered.

Those are definitely part of the care at the Johns Hopkins Hospital. Some of the unique additions to recovery care in the last year to 2 years now have enhanced our outcomes for patient care.

Dr Salas: That's great. That sounds awesome. Do you mind sharing with our audience, maybe some of the unique features of your particular unit? I know that you all are leaders in the field. People are always interested to know where you are. What are you doing that's innovative? What's your vision? Where are you going?

Dr Bahouth: I long felt—and this audience is very familiar with stroke—it's a leading cause of adult disability. Patients, 1 minute are highly functional, interactive, and in 1 flash of a moment, their lives change to have highly disabling symptoms that affects both the patient and their care partners in an instant.

I've long been a part of the hyper-acute treatment protocols which focus on how quickly can we deliver re-vascularizing treatments. I've been worried that a lot of effort and dollars have been put to the hyper-acute treatments, and rightly so.

A lot has not advanced in the area of recovery care. How do we get behavioral recovery advanced? Our unit took a key focus to say how from day 1, can we start the idea of brain recovery on our unit?

To do this, we merged a trifecta. We wanted to get the right level of expertise from the interprofessional team, highly expert people to the patient at as many hours a day as possible. Secondly, we've integrated a lot of cutting-edge technology to extend the reach of our therapists and our treatment team.

How can we get people motivated to get involved in their recovery care? How can we get them interested in some of those things? As some of my colleagues said, you can only play with a ball of play dough for so long. If we can get motivating games into the system and space, that will be highly useful to the patient.

Then last, we thought that gathering critical data about how are we affecting individual-level recovery would help that individual as well as the next patient who came in with a similar profile of symptoms to our stroke unit.

I would say some of the innovations are in the personnel, getting the up to 3 hours per day of therapists’ time, which is unheard of in the acute hospital stay. Integrating key technology that motivates patient to high-quality, high-intensity movements that are critical to some of their recovery.

Then coordinating some programs that follow the patient along the continuum of care so that we're sure the minute they leave the hospital, all of the things that we started translate into their real life effectively.

Stroke is a problem. The brain injury is a problem. Some of the secondary complications are equally devastating to the patient's recovery. We wanted to have a system that could catch any problems along that entire system.

Dr Salas: That's amazing work. That's kudos to the unit, the whole team. Mona, before we go back to hear from Debbie, I'd like to know, what made you consider to be interested in SIBR—at least bringing this idea and this process to your unit? Looking forward, how could this potentially improve what you're already doing, which is amazing work?

Dr Bahouth: I'll say nothing will benefit a patient unless the patient is involved in the plan. Forming an alliance with every single patient, no matter where they are in their adaptation to a new disease or their recovery from a new disease, is critical.

If we could have the patient central to the model understand that individual's need so that we can take this great system around them and modify it to exactly meet what the patient needs in real-time, then we’ll know that we've won.

Many times in health  care, the reality is that we're moving so quickly. The patient is sitting there—especially with neurologic conditions—not quite understanding what's going on, not quite understanding the plan of care. They're the ones that need to pick up the ball and run with it with their loved ones when they leave the hospital.

To me, this whole idea of SIBR was critical and at the perfect time. We need to make sure our patients are empowered. They're at the center of the team model. I also thought it was going to be a bit of a challenge since not all stroke patients have the cognitive ability to be in the middle of rounds.

It creates some unique challenges to the area of science related to SIBR. We had some interesting and unanswerable questions until we did a study like this. Can we do it? Will bedside rounds help the patient? Will it in fact hurt some patients who have some cognitive issues that might make it feel overwhelming?

I thought they were important questions to ask. I'm excited to have such experts bring the scientific approach to our unit. It's just a great place to try to extend the care and continue to enhance our patient-focused, patient-facing care at the bedside.

Dr Salas: Great. Debbie, why don't you share with us a little bit about the team. Obviously, SIBR work has been done. You mentioned earlier the congestive heart unit and a few other units across the country being led by other groups.

For us, I believe our institution is the first to look at SIBR in a stroke recovery model, nonetheless. Did you want to share maybe like who makes up the study team? Why a stroke unit? Why was that a good fit?

Dr Dang: The study team actually has been meeting before we actually started the study. It was a highly interprofessional group of colleagues who had, as their central focus, opportunities to enhance collaborative practice in the care setting. One thing I forgot to mention, which is one of the many unique things about our study, is that we are also including learners as members of the team.

This is so important because they will be able to see firsthand role models of how collaborative practice can work in support of patients and families. Also in terms of the quality of the decision-making for care planning and care treatments among an interprofessional team, as leaders in operations, we have a responsibility to create an environment that allows students from our health  care professions to take what they've learned in their educational programs, and have an environment that supports them practicing it.

Those are all the environment around which we're doing this study. The actual SIBR model has maybe 6 or 7 standardized processes to it. Those include things such as having bedside rounds be done at the bedside.

A lot of organizations have implemented multidisciplinary plans of care at our institution. We found that those weren't as effective for the clinicians because they were typically held in a conference room, and the interprofessional team was all there except for the nurse because the nurse was out taking care of the patients in his or her assignment.

Then the nurse would be called in, and they would give an update, but then they'd have to go back to patient care. It wasn't effective because they're the one profession that's with the patient throughout 24 hours. They have insights that can contribute to developing the care.

These rounds occur at the bedside. They begin with a standard team of professionals that the unit decides are the core rounders. When they move from patient to patient, they put a system in place to notify the nurse that in 10 minutes, they're going to be rounding on that nurse's patient, so the nurse has the opportunity to make arrangements to be available.

The other components are that there are well-defined roles for every member of the team and the clinical team defines those. The rounds are designed to be 10, 15 minutes, or less. The focus is to enter the room, invite the patient to participate, and even give the patient a choice to not have the rounds be done in the room.

There was a whiteboard in every room that when the team is going through the rounding, it consists of information about what the patient's daily goals are, what the clinical team's daily goals are, and who the core assigned caregivers are, the nurse, the physician, the pharmacist, and the names of those individuals.

The focus of rounds is on completing that whiteboard and making that information visible so that everybody agrees and sees that they're all working towards the same goal.

Dr Salas: Great. That was a nice run-through of what SIBR is, just in the standardized structured part of it. What made the stroke team here, the brain recovery unit more specifically, a good fit for this study?

Dr Dang: Several things. Number 1, there was high interest by both Dr. Bahouth and the nurse manager. That's critical because they were both interested in trying this new approach, and that is critical to the success of the rounds because they set the standards and the expectations about how care can be delivered.

They're there to support the care team in providing resources and information, along with the study team. The stroke unit was particularly of interest for 2 reasons. Number 1, because we knew that, as Dr Bahouth mentioned, not all of the patients are cognitively able to participate in rounds, and so we wanted to study. That was one reason.

The second reason was we've been in this COVID mode for quite a while, and we know that visitation policies by family members are pretty restrictive. We were interested in exploring a couple of measures around patients and family, and their focus as members of the team.

Number 1, we wanted to make sure that we wanted to collect information about patients when they can communicate their level of comfort in speaking up during rounds, asking questions, their interest in engaging, and setting their own goals.

We also wanted to take a look at how we could engage the family as a participant, even if they're not physically there. Those were the major factors that we thought would be very important to generate some information about so that we can generalize it beyond just the stroke unit.

Dr Salas: Great. Mona, back to you. When you brought this to the bigger team, how did people on the team respond to this? I know typically what a lot of teams do is, they'll round in a protected space. Even if it's in the hallway, it's away from the patient, they put the plan together.

Then traditionally, we would go into the room and tell the patient, like, "This is what we're going to do. You're going to get this test, discharge here, and blah-blah-blah." Your rounds were previously in a conference setting. You were around a table discussing each patient, and then you would do the traditional rounds.

I guess you can elaborate a little bit more on how your rounds currently are because we haven't done the intervention just yet, but then also the response is, were people interested in doing this, or were they not at all sure about it? Please share.

Dr Bahouth: Yeah, that's such a great question. The short answer can be that all humans initially resist the idea of change. That would be the short answer. The complex answer would be that the stroke service is notoriously, fairly heavy with its census, its number of demands on all levels of staff, the nursing staff, that ratio of patient to nurse, the physicians who see patients both on the stroke unit, as well as consults to the hospital. There are acute stroke calls that need tending to.

The initial first response was, "Will this add a lot of time to our rounds?" because we know for the learner, if rounds go on beyond a couple of hours, we will lose their attention and ability to enhance their learning.

Second, that patient work will come to a grinding halt and slow the process for patients who need the care delivered. Everybody's first response for many good reasons were, "This sounds like it will take a lot more time."

The reality though, when I read some of the science was that in fact, it might reduce the amount of time on rounds if done properly. That was part of the question we needed to ask ourselves. Luckily, we work with the most tremendous stroke division who are very open thinkers and willing to try things that may benefit patient care.

I would say there is not a single person in the stroke faculty who you won't go to with an idea, who might just say, "Well, wait a minute," but then would immediately jump in to help. People are for trying it. They're curious about how it will go, but I will say their main concern is time management.

Just to talk about our current rounds, they have been tweaked over many years in generations even before me, the way rounds work in the stroke unit because it's such an interprofessional project.

Basically, we start in the intensive care unit rounding on the sickest of patients first with the Intensive care unit team, the neurocritical care team, we see those patients.

We then move to the intermediate care unit where we start staffing any new patients who arrived to the unit, or any patients who are unstable or sick. That tends to happen in a room where there's a nurse present, as well as the interprofessional team. Sometimes there is a pharmacist with us. Sometimes there's a physiatrist with us.

The purpose of rounding in a side room was so that the team could rapidly hear the clinical presentation, review the diagnostic tests, look at imaging, and come to a therapeutic plan rather quickly together.

Within that period, as we move through our census of rounds, we go to the multidisciplinary rounds, which is where all the magic happens. This is the team of people who make sure that patients are efficiently discharged from the hospital, with all the resources that they might need.

Here, the stroke team goes to present the patients, talk about the discharge needs, and have contributions from the case manager, the nursing staff, the therapists, the social workers, the pharmacists to expedite care and assure that discharge to the next destination is as safe as possible.

Once all those non-bedside parts are completed, we move to the patient rounds where we go to each room, do a neurologic exam, communicate any updates with the patient, and hear any issues that the patient is having that we might need to address.

It tends to take most of the morning, I would say. As we were thinking of the SIBR process, we wonder how it would fit into the current model, or blend to change our base model of how we do this. We'll see over time. We're excited to find out.

Dr Salas: I can chime in there that, at the moment, you're in an observation phase. Debbie had been awarded some pilot funds to start this process, and she's been observing. Why don't we hear a little bit more about that, Debbie? Where are we in this study? What are we doing right now, and how is that going to benefit Mona and the team?

Dr Dang: Sure. Thank you. That's a good question. Before I answer that though, I would like to just build on something that Mona said. This model has been implemented at a number of academic medical centers across the country.

Our model is adapted from the University of Washington model. Kevin O'Leary, who is at Northwestern, did some of the initial original papers on the importance of interprofessional practice, collaborative practice, and how that benefits not only the team but the patients.

What they found in their work is that rounds, when done according to using the components of SIBR—they have shown that it's more efficient because everybody on the team has the same information, and everybody knows the same plan of care for the patient.

It decreases pages to the physician throughout the day, and it allows more efficient planning for patients that have to go off the unit. That's an important part of the model. Where we are with a study right now—it is grant-funded. We are in the first phase of the study.

Phase 1 is observation and data collection of the current state on the unit. That includes direct observation of rounds, and a relational coordination survey, which has already been administered to all members of the team on that unit. This relational coordination survey—it's 7 questions, and it's been used at the University of Washington.

Between the observation data and the survey data, the study team will conduct focus groups with the clinical team on the unit to present the data, the elements of SIBR, and identify opportunities to implement those components of SIBR in a way that meets their workflow. We anticipate that we'll have that data after the holidays, maybe early spring.

Phase 2 is once the data is presented to the team, and they decide what the design and the content is going to be—phase 2 is implementing that process, and then having observations and, through regular meetings on the unit, tweaking it so that if there's a problem or a snag, that it can be smoothed out just in time.

Phase 3 would then be evaluating the fidelity of the implementation and the outcomes on all of our measures for the study.

Dr Salas: Great. Mona, how's that so far for the team right now? Being observed especially right now since when we initially had started this whole—we just had discussions about this. COVID had not hit. Do you want to tell us how things are going or new concerns that might have come up in the setting of COVID?

Dr Bahouth: I think we are a really thoughtful study team, so when COVID struck, we really did make a lot of thoughtful pivots to be sure safety was of course at the top of the list. We quickly got assistants well-integrated at the Johns Hopkins Hospital. Research restarted after a couple of months of shutdown.

I think the time in-between was well-spent in terms of planning with the study team. In terms of the observational study itself, it always changes the dynamic to have an observer, but with the methodology here, we really notified everybody that there would be an observer.

We didn't really talk about the hypothesis of the study or what the observer was looking for per se. There was a human factors engineer, I believe, the first day to make sure that the observations were being recorded properly.

Otherwise, the observer has really done a great job to blend into the team and just make observations, that normal routine could be captured. It's one of the limitations of this kind of science, but I think we've done our best to limit any bias from it. I think it's going well.

We're excited to hear the observational feedback. We always think every system can improve, and we're looking forward to hearing what we can learn from these observations, number 1. Then number 2, how we can move into the sort of bedside rounding approach once we make that plan.

It definitely has slowed our process. COVID has really impacted us in many ways, but I think everybody has the fire to get this going and keep completing this as we go forward and keeping safety of course at the top of the list.

Dr Salas: I think that's great. Do you want to comment—I know initially, in discussions embedded with this whole study and process, is really the opportunity to complement professional development of several of the team members.

Not only are we going to get data back regarding your team and how it's functioning currently, but you also want to come up with your own SIBR though your own TeamingUP model for the brain recovery unit. There's actually going to be some training.

There's going to be some skills to be learned. I think this really enhances not just the physicians with this new process, but nurses, whoever wants to really engage with the process and truly be a champion.

Do you want to say anything about leveraging that opportunity, that this is not just a straightforward stay—there's really professional development, and I'll have Debbie in a second talk about the wellness component as well?

Dr Bahouth: I see this project as such a win-win mostly for the patients if we can optimize our system, but most certainly about the team. Stroke is a team sport. There's no doubt about it, and communication and successful communication—when you have it, this system works great.

When communication has breakdowns which often it can in stressful environments, we reflect back, try to learn, and move forward. I only see this as a win-win for a staff for our inte-professional communication style and team growth.

My husband may tell you that's because I'm a painful life learner and have always thought that education was how you moved to your next step. In terms of team health care delivery, it's really the only way to keep looking at your communication and optimizing it.

We have created a complex system where we have many interprofessional contributors to the patient team. It's a great time for us to really learn about our communication style and enhance it through the TeamingUP education that's coming our way. I see this as a definite win-win.

Dr Salas: I know we're getting close to the end here, and I definitely would not want to close this out without talking about the wellness component, especially right now where everybody had a burnout and even rubout. It's for the nurses, it's for everybody, everyone across the health system.

Debbie, do you want to comment on how this SIBR model is addressing that or at least looking at it?

Dr Dang: Yes. At Johns Hopkins Medicine, we conducted a study several years ago when the issue of burnout came out among all health care professionals. Looking at that data, it included physicians and nurses primarily.

Physicians, interestingly, what we found were that the physicians that answered and responded to that study had a lot of comments about the lack of team-based care and how that interfered with their ability to work interprofessionally.

They really valued that component and not having it actually contributed to their low well-being. It wasn't the only factor, but it was a common thing that came up when we did the qualitative survey.

There is a lot of evidence not only for interprofessional collaboration that, during this time of COVID, that social connection among people and teams is the greatest predictor for resilience both individuals and as a team. Using that research information, we built in 2 measures that we're going to be using that we know are good measures of well-being.

One is that of psychological safety. Amy Edmonson has done a lot of work in that area, as has Google and work with MIT that show that psychological safety is a big predictor of team communication, team safety, and team effectiveness. We're going to measure that.

We're also measuring clinician well-being. We're using a survey that really gives the clinicians an opportunity to answer a number of questions related to how they perceive themselves and their teammates in the team.

We know from work at University of Washington that those surveys and the relational coordination survey, that data really help them address what they found was a problem in their rounds.

With that, nurses were afraid to speak up, and physicians were not happy with the length of time that they had to spend answering pagers and calls and the things like that in between rounds.

I think that the thins that's exciting about what we're doing is, it's covering a lot of basis so that it's not addressing a single intervention. This one structure can really address patient-centered care, team communication, team effectiveness, and team wellbeing.

Dr Salas: I think that's great. I think it's a nice way for the group to really contribute to the science that's out there already looking at SIBR model bringing in, not only the learners that we spoke about earlier, but the well-being of all of the health care teams that are providing this care, hopefully helping the patients' voice be heard a little bit more with their goals and their intentions, because a lot of times, as clinicians, our goals for the patient may be very different from what their goals are.

I look forward to seeing how this rolls out and how Mona's team will really take it to that next level and really be a leader for not only other stroke units, but for other critical care units as well. Mona, as we end here, do you have any last words that you'd like to share?

Dr.Bahouth: I think one thing that I'm not sure if I emphasized enough that could be a benefit with this model is really the care partner readiness for the stroke patient discharge, so when the patient goes home, a lot of the care coordination really falls to the care partner, the family member, or a friend.

This is really educating patients and their family members during a crisis not always ideal. We have created structures to provide the continuity and care through some of our J-STEP program, etc.

As I really reflect on the SIBR program, if this contributes to family readiness for patient discharge because they feel more involved in a daily rounds, this is also one of the potential gains that I see as important for doing such a project. Although COVID is trying to strip us of that family involvement, we are just finding creative ways to bring the patient to the bedside virtually.

As we design our intervention, it will be critical that we keep that family member as a focus in this process, because they will be one of the successes if this program has the highest success that I'm sure it will.

Dr Salas: Thank you, Mona, for bringing that up. I think that's a very important piece that Debbie has been focused on as well, as that caregiver or the family component and something that the study is very interested in. A lot more to come. There's some fabulous things going on at Johns Hopkins Hospital.

We look forward to seeing the outcome of the study and how the clinical team changes and what the clinical team is going to look like in the future. Hopefully, we can do a part 2 once this is all said and done and really show the outcomes. I want to thank both of you for taking the time to discuss.

I hope our audience knows a little bit more about what SIBR is and the advantages of thinking about implementing it into your team. Whether that's an inpatient team or even an outpatient team, there may be some benefits there to consider.

Hang on tight and we'll have some outcomes soon enough, and maybe that will convince you then. Thanks again, and we'll see you next time.

Dr Bahouth: Thank you.

Dr Dang: Thank you, Rachel.