Abstract 34: A Stroke Transition Of Care Intervention With Stroke Nurse Navigator And Early Stroke Clinic Follow-up Reduces Readmissions For Stroke At 12 Months

Abstract

Introduction: Stroke is a leading cause of disability in the United States, and one in four occur in people who have already had a stroke. Preventable hospital readmissions contribute to the high medical costs of stroke. Transition of care programs have been successful in reducing hospital readmissions in other diseases, but the data on such programs for stroke is mixed. A transition of care program was implemented at a large urban stroke center, utilizing interventions shown to be effective in the literature, with the goal of reducing recurrent strokes and hospital readmissions. Methods: The transition of care program consisted of: two Stroke Nurse Navigators, personalized stroke education in the hospital, two-day phone call reinforcing education and reviewing medications, early follow-up within 7-10 business days with a Stroke Neurologist, and further education on personalized risk factors in the clinic. Baseline data from the year prior to intervention, and each quarter of the three-year project period were obtained on the following measures: Rate of recurrent stroke admissions within one year, all-cause readmission within one year, all-cause readmission within 30 days, patient scheduled for initial follow-up within 7-10 days, compliance with follow up in the stroke clinic, and percent of patients receiving two-day post discharge phone call. Discharge data were reviewed on 949 patients in 2016 (year 0) and on 2,328 patients in the three-year project period (starting in July 2017). Results: The rate of readmission for stroke was 8.5%, 9.0%, 6.6%, and 4.2% for year 0, 1, 2, and 3, respectively. This represents a reduction of 50% from the year prior to the intervention to year 3 of the grant. All-cause readmission remained stable, at 38.9%, 42.6%, 36.6%, and 37.4% for year 0, 1, 2, and 3 respectively. An improvement was seen in process measures: patients scheduled for early follow up in the stroke clinic, adherence to follow-up, and two-day post-discharge phone calls. Conclusions: In conclusion, the transition of care intervention led to a reduction from baseline in readmissions for stroke within one year, but did not impact all cause readmission at one year or 30 days. This is a meaningful outcome for those who have suffered strokes. This program can serve as a model.