Abstract WMP109: Transitional Care Matrix to Improve the Coordination of Stroke Care Between Inpatient and Outpatient Care Settings

Abstract

Background and Purpose: Transitions of care, specifically between inpatient and outpatient care settings can be a point of vulnerability in the care of stroke patients. As patients transfer from inpatient care facilities to outpatient clinics, information can become lost resulting in delays in care, a slower recovery, and patient and family frustration. The purpose of this program is to provide a link between the inpatient and outpatient care settings and improve the coordination of care along the continuum by communicating to the outpatient providers essential information about the stroke patients they will be seeing for follow up. Methods: In order to improve the transition of care between care settings, a two-part program was used. First, the Stroke Advanced Practice Nurse along with the inpatient Neurology team completes a discharge timeout to collect and verify essential information, such as the final diagnosis, suspected stroke etiology, discharge medications, follow up appointments, and transitional care issues such as pending studies. This information is then compiled into a transitional care matrix, which is shared on a weekly basis with the outpatient clinicians who will be seeing the patients that week, allowing them to anticipate and prepare for the follow ups and the patients’ needs. Since initiation in April 2018, 95 stroke patients’ plans of care have been reviewed using the above process. Results: Use of the discharge timeout and transitional care matrix has resulted in improved transitions of care. The process has resulted in more consistent and prompter scheduling of follow up appointments in the outpatient stroke clinic. Furthermore, the transitional care matrix that is shared with outpatient clinicians has helped them to be more prepared for appointments and has created an atmosphere of collaboration between different stroke providers. Conclusions: In conclusion, the discharge timeout and transitional care matrix process has shown to be a valuable tool in the transition of care for stroke patients between the inpatient and outpatient settings, resulting in fewer delays in care and improved anticipation of care needs.