Abstract 079: Preliminary Outcomes of a Survivor‐Centric Digital Platform in Stroke Recovery

Abstract

Introduction This study evaluates the feasibility of a survivor‐centric, navigator‐driven, and technology‐enabled platform supporting survivors and care partners in post‐stroke recovery. We hypothesize that post‐stroke navigation can favorably impact stroke recovery through monitoring medical and behavioral health factors, social needs assessment and support, curated educational content, evidence‐based interventions, and clinical guidance. Methods An app‐based, virtual care model was used to increase survivor quality of life and improve outcomes for stroke survivors. This mixed methods study utilizes both focus group feedback, survey, and patient‐reported outcomes data along with digital engagement. Participants (n=40) were facilitated by a clinical navigator (occupational therapist or licensed clinical social worker) through understanding lived experiences and health‐related motivators. Stroke survivors and their care partners, if they have one, were referred from one of four partner hospitals by the primary stroke team during the pilot program (starting July 2022) prior to their discharge. The Navigators worked through phone, messaging, and video calls with the stroke survivor and their care partner who had shared access within the app but had separate profiles. The duration of participation was a median of 12 weeks but could be as short as 2 weeks based on individual needs including post‐stroke impairments, social determinants of health, resource needs, education and health literacy, risk factors and lifestyle management, as well as mental health support. The average participant had 9 Navigator touchpoints totaling 6‐8 hours over the 12 weeks. Results In this feasibility study, clinician‐assessed mRS scores were captured at 90 days following hospital discharge for 95% of participants. This is similar to the results recently reported for another clinician‐supported, app‐based post‐acute platform in Spain. Significant functional improvement was seen over time, with 84% achieving mRS scores of 0‐2 at 90 days, compared to 60% of participants at the time of enrollment. 88% of enrollees completed the validated Take Charge Intervention. The 30‐ and 90‐day all‐cause readmission rates for survivors were 6% and 12%, respectively. This is superior to recent publications reporting 30‐day unplanned readmission rates after stroke ranging from 8.7%‐12.5%, and 90‐day readmissions ranging from 18.9% to 20.7%. Nearly all (96%) of the stroke survivors that participated in the program reported adherence to their medications, compared to a national average of 64%. At 90 days, 90% of enrollees had completed a neurology follow‐up visit. Among the 15% of participants who did not have a primary care physician (PCP) prior to their stroke, the Navigators were able to assist in establishing care with a PCP for all of them. The demographics reflect typical stroke populations: Ten percent of the enrollees were on Medicaid or uninsured at the time of their stroke, more than half were non‐white, and 20% had five or more needs related to social determinants of health. Conclusion This feasibility study demonstrates that a tech‐enabled healthcare services program can engage and impact the outcomes of individuals and care partners during stroke recovery.