Abstract WP56: Neuroscience Nurse Navigator a New Compass in Continuation of Care Among Stroke Populations

Abstract

Background and Purpose: Due to continued growth in our neurosciences program, of more than 1,400 discharged stroke patients per year, we saw a need for the creation of a Neuroscience Nurse Navigator (NNN) position, with initial efforts specifically focused in the stroke program. This role was developed as a means to meet and fulfill Joint Commission recommendations, along with the Comprehensive Stroke Certification (CSC) standards. Prior to the NNN role, compliance for attempted patient callbacks (a CSC requirement for those discharged home) was only 70%. Resources to support patient needs post-discharge were limited. Method: The process in creating this role began in 2020 and came to fruition in 2022. As a means to address patient call back compliance, those patients who have been identified as having a stroke, are visited as a point of introduction, also allowing time for unanswered questions. All stroke patients are called within a seven-day window, including those on our Neurosurgery service line. Patients are asked a series of 12 pre-set questions with calls varying from 6-10 minutes. To address the issue of post-discharge resources, the NNN aids in facilitating and arranging follow up appointments and is available to assist with patient questions prior to follow up appointments. The development of the stroke support group was initiated as well. Working with marketing and IT, the NNN created the Brain Matters stroke support group, which includes an informational postcard with QR code provided to stroke patients at time of discharge, and a separate email account. Patients can use this email to ask for a registration form for Brain Matters and allows the facilitator to communicate to the group as a whole. Results: Since implementing the NNN, attempted call-back rate among the 7-day calls have reached 100%, and completed call-backs (patient or family reached) increased from 70% to 85%. In relation to post-discharge resources, the creation of the Brain Matters stroke support group has been implemented and data is currently ongoing. Conclusion: The future plan is to further develop the NNN role as a necessary resource for all patients within the entire Neuroscience service line, including General Neurology, Epilepsy and Neurosurgery, as they navigate toward recovery.