Abstract TP365: Stroke Nurse Navigator Improves Post-Acute Transition of Care

Abstract

Background: Post stroke care is multifaceted and should not end at hospital discharge. Patients often lack understanding of the importance of outpatient care to prevent secondary stroke. Objective: To demonstrate the positive impact of a stroke nurse navigator in improving the post-acute transition of care by promoting outpatient follow up after hospitalization. Methods: We retrospectively reviewed all patients discharged from our comprehensive stroke center (excluding hospice) with a primary diagnosis of ischemic or hemorrhagic stroke from January -December 2018, yielding 685 patients. We evaluated whether or not our nurse navigator influenced three aspects of follow up: if stroke clinic appointment was made before discharge, if patient attended the appointment and if patient called the clinic after discharge. Four categories were used based on level of navigator contact with the patient: (SC) Seen in-house and called within 30 days after discharge, (S) Seen only, (C) Called only or (N) No navigator contact. Chi-square test of proportions was used to evaluate the statistical significance among all four groups. Results: Out of the 685 patients, 77.5% (n=531) were scheduled for clinic follow-up before discharge, 60.7% (n=416) attended the appointment and 20% called after discharge (n=137). The distribution of navigator contact level was (SC) 26.7%, (S) 17.5%, (C) 19.3% and (N) 36.5%. Both seeing and calling the patient was proven to be the most effective in all three areas: appointment made prior to discharge (SC) 89.6%, (S) 82.5%, (C) 74.2%, (N) 68% ( p=<0.001 ); patient attended the appointment (SC) 68.9%, (S) 60%, (C ) 65.9%, (N) 52.4% ( p=0.001 ) and patient called the clinic after discharge (SC) 26.2%, (S) 15.8%, (C ) 23.5%, (N) 15.6% ( p=0.02 ). Of interest, patients who were only called but not seen were more likely to attend the appointment or call the clinic as compared to being seen alone. Conclusion: Contact with our nurse navigator increased post-acute follow up in our stroke clinic. An increased number of patient calls associated with navigator interaction showed these patients had a better understanding of the need for continued care. The nurse navigator improves continuity of post-acute care.