Abstract T P350: Bridging The Gap Between Acute Care and Public Health

Abstract

Background: The WHO estimates that only 50% of patients with chronic illness adhere to treatment recommendations. The Affordable Care Act targets hospital readmission rates as cost savings opportunities. Transitional care programs have been shown to improve patient outcomes. Purpose: To reduce readmission and recurrent stroke, the Stroke Patient Education and Navigation (SPEN) Pilot Project sought to enhance the continuum of care post discharge by forming collaboration between the University of Louisville Stroke Center (ULSC), Taylor Regional Hospital (TRH) and the Department for Public Health. Primary outcomes of this one-year pilot were hospital readmission rate, medication compliance, and utilization of community resources. Methods: Stroke patients transferred from TRH to ULSC discharged home were invited to participate. Upon d/c home nurses made three home visits (2 weeks, 3 months, and 6 months post discharge) to assess outcomes and to obtain demographics, PCP, whether patient was receiving rehab, mRS score, BMI, vital signs, labs, vascular risk factors, patient/caregivers’ ability to measure their own blood pressure, verbalize stroke symptoms, behavioral modifications since hospital discharge, and self assessment of perceived health status. Results: 21 patients agreed to participate in SPEN, 3 of whom did not complete the study. The average time per 1 st , 2 nd , and 3 rd nurses’ visits were 4 hours, 3.2 hours, and 2.9 hours respectively. The total cost of 56 health department home visits, including travel and expenses was $12,219.02, a cost per home visit of $218.20. The cost per patient for the project was $581.86. 95.2% adhered to their medications as prescribed. No patients were readmitted to the hospital within 30 days. Only one person (4.8%) participated in a community resource, a smoking cessation program at the health department. Most sited that they did not utilize community resources due to lack of transportation. Conclusions: SPEN results revealed excellent medication compliance, no hospital readmissions within 30 days, but low community resource utilization. The sample size was small and limited to six -month follow up. Further outcomes and cost analyses can be obtained with a larger sample size and extended follow up.