Abstract WP500: Stroke Transitions of Care Coordination Program is Feasible and May Reduce 30-day Readmissions

Abstract

Introduction: Transitions of care from the acute hospital to other medical facilities and home is a national health care priority. We designed a randomized pilot study to assess the feasibility of a Transitions of Care Coordinator (TOCC) program led by a nurse navigator. We hypothesized that the navigator would complete all portions of TOCC program in at least 75% of acute ischemic stroke (AIS) pts. Methods: Consecutive AIS patients admitted from April to July 2018 were randomized to TOCC group or usual care group. Pts discharged to subacute rehab, nursing home and hospice or died during hospitalization were excluded. In TOCC, the navigator met patient/caregiver on admission, followed up discharge pending diagnostics, attended multi-disciplinary rounds, facilitated rehab referrals, provided stroke education, and arranged clinic follow-up. Demographics, NIHSS, mRS and discharge disposition were collected. Hospital length of stay (LOS) was calculated from date/time of patient registration to discharge. Patient satisfaction questionnaire and readmission rate was assessed at 30 days by phone. Continuous variables were analyzed using Wilcoxon rank-sum and categorical variables using Fisher’s exact test. Results: TOCC pts were older, but other demographics were well matched (table 1). The navigator completed all portions of the TOCC program in 80% of pts. The mean time spent by the navigator per TOCC pt was 111 minutes (SD 23). There was no difference in distribution of LOS between the TOCC and usual care groups (5.7 vs. 5.1 days, p=0.51). There was no difference in the mean patient satisfaction scores between TOCC and usual care groups (30.3 vs. 29.6, p=0.66). There were no 30-day readmissions or ER visits in TOCC group vs. 3 and 2 in the usual care (p=0.25, p=0.50). Conclusion: A nurse navigator-led TOCC program is feasible and may be associated with decreased 30-day readmissions. The ongoing TOCC study will assess any association with LOS and patient satisfaction.