Abstract TP28: Stroke Care Doesn't End At Hospital Discharge: What Patients Need After Hospital Discharge May Not Always Be Obvious

Abstract

Introduction: Mood disorders after stroke are common, with up to one-third of patients developing depression and/or anxiety. Identifying those at greatest risk may be challenging in the acute care setting. We sought to better understand post-hospital barriers impacting emotional well-being for those who suffered a stroke and to evaluate needs for additional resources post hospital discharge. Methods: A Stroke Transitional Care Program (STCP) was initiated at a large two-campus hospital in Southern California in October 2020. All patients discharged home with acute ischemic stroke (AIS), hemorrhagic stroke (HS), and transient ischemic attack (TIA) received a follow-up phone within 3-7 days of hospital discharge from a community health worker familiar with the community and language. An initial needs assessment was completed over the phone to evaluate barriers for post-hospital care, address social and economic needs, and help patients navigate the healthcare system. Data from the initial needs assessment results were analyzed and 30-day readmission data reviewed. Results: A total of 145 patients with a stroke diagnosis were discharged home between October 2020 and June 2021. Of those, 68.3% were discharged with AIS, 21.4% with TIA, and 10.3% with HS. Initial assessments of the 100 patients accepting enrollment into the STCP were reviewed. Fifty-six patients required additional resources, of which 55% required counseling, emotional support, and/or mental health resources. Nine percent of patients were readmitted to the hospital within 30 days. Of these, 22% were admitted for isolated psychiatric issues. Conclusion: A large portion of the stroke patients in our analysis required additional resources post discharge to support emotional well-being, and 22% of patients who required hospital readmission were admitted for psychiatric issues. As a result of these findings, our STCP incorporated the PHQ-2 screening as a standard part of initial post-discharge assessment and implemented a referral process to mental health services. Our results suggest the need for stroke programs to consider implementing processes to assess emotional/psychiatric needs for stroke patients post discharge by incorporating community-based models of care.