Abstract TP35: Stroke Nurse Navigation-Evolving Care Delivery To Effectively Meet The Needs Of Stroke Patients And Families

Abstract

Background: Research indicates the importance of life-style modification, risk factor management, and medication and physician follow-up compliance in the prevention of stroke. Nurse navigators are in a unique position to influence this care. The pandemic changed post-acute management of stroke by requiring increased virtual care as opposed to in-person care. A known disparity existed in the number of touch points between the patients utilizing the patient portal versus those reached only by phone. We aimed to evaluate how changes in navigator workflow influenced the frequency of touchpoints, operating under the assumption that increased touchpoints will improve post-hospital care. Methods: A retrospective analysis was completed for acute stroke patients discharged from January 2020 - March 2021 for 4 certified stroke centers. We implemented standardized time intervals for patient outreach, regardless of modality. Initial outreach was completed within 48 hours to avoid potential gaps in care. Motivational interview calls were focused on education that included life-style changes, compliance, risk factor control and follow-up, which mirrored the mobile application’s education. Branded individualized education materials were created and sent to patients using US Mail or via the patient portal. New flowsheets were developed in the EMR for future data collection and reporting. Hand written notes and cards of encouragement were also sent reinforcing the counseling received. Linear regression analysis evaluated our primary outcome: the relationship between monthly touchpoints over time. Results: A total of 1935 patients were diagnosed with acute stroke, discharged and managed post-hospitalization for 90 days. During the 90 day episode, navigators interacted with patients for M = 4.64 SD = 2.46. Regression analysis demonstrated a linear relationship between time and touchpoints ( p <0.001). Navigators also reported intangible results from patient and family feedback related to support and care received. Conclusions: Stroke care is complex and requires ongoing patient and caregiver support. Increasing availability to stroke experts, such as nurse navigators, provides support and tools to improve post-hospital care.