Abstract WP50: Analyzing Post Discharge Follow-Up of a Disparate Population Utilizing Mobile Integrated Health

Abstract

Introduction: Transition of care (TOC) to home for many stroke patients is suboptimal. Recent studies estimate 30-day all-cause readmission of stroke patients at 17.4%. The Wisconsin (WI) Coverdell Stroke Program partnered with the Milwaukee Fire Department- Mobile Integrated Health Program (MFD-MIH) and Milwaukee County hospitals three times since January 2019. The aim of our MIH focused partnership was to improve follow up care and care coordination after an acute stroke hospitalization to a vulnerable urban population. Methods: A charter, project algorithm, and referral forms were created to guide our work. Patient referral forms and MFD-MIH home visit summaries were sent via secure email. Upon receiving a home visit referral from the hospital MFD-MIH attempted to engage the patient within two business days. After a completed visit, MFD-MIH sent a summary form to the referring hospital mimicking post-discharge data metrics in Get With The Guidelines® (GWTG). Upon receiving the summary form, hospital abstractors entered the data into GWTG. The data was then analyzed by the Coverdell team. Results: As of May 2023, 73 stroke patients have received a home visit from MIH-MFD with data entry in GWTG. Analysis of the third iteration of the program will occur after it ends in April 2024. We compared our first two MIH projects to all Wisconsin hospitals entering into the GWTG Post-Discharge tab. Our results showed: • Coverdell MIH hospitals outperform WI hospitals in Blood Pressure Monitoring by Patient and Appointment Scheduled Prior to Discharge • Coverdell MIH hospitals underperform WI hospitals in ED Visits , Falls Reported by Patient , Medication Stoppage and Tobacco Use Conclusions: Many factors influenced our data. First, the population in the Coverdell MIH program was from an urban environment with more proximate post-discharge resources. All WI hospitals do not share this setting. Secondly, MIH data collection involves an in-person home visit. Conversely, WI hospitals data collection occurred via a phone call or chart review. The Coverdell MIH method facilitates a collegial environment where more truthful disclosures may result.