Abstract WP323: Challenges Implementing a Nurse-Led VA Transitional Post-Stroke Program

Background: In the U.S., the average acute care length of stay is 4.5 days. Despite advancements in acute care, advances in post-stroke transition have lagged. Post stroke transitional care is fragmented and unorganized leading to higher hospital readmissions, poor patient outcomes, decreased functional status, and increased caregiver burden. We discuss our experiences in implementing a nurse-led, post stroke transitional program. Purpose: To evaluate the feasibility of implementing a Nurse-Led Transitional Stroke Program (NLTSP) based on the transitional care model. Methods: Acute stroke/TIA veterans discharged home from local VA or surrounding non-VA facilities were invited to participate in the 90-day NLTSP. Inclusion criteria included veterans discharged home with a diagnosis of stroke. Patients received a 2-day post stroke call, offered an outpatient follow-up visit with a stroke provider, and received a 90-day post stroke call to conduct a modified Rankin Scale (mRS). See figure 1 for patient acquisition process for non-VA facilities. Results: Over a 12-month period, 1356 veterans were screened, and 600 veterans were contacted for enrollment. A total of 326 veterans were enrolled into the NLTSP ( figure 2 ). On average, initial phone calls of those enrolled were made within 3.5 business days of discharge. More than half (56.1%) of the veterans were discharged from non-VA facilities. The average age was 69.9 with 93.3% being male. The average number of days from discharge to outpatient follow-up clinic appointment was 27.4 with 81.3% of patients completing enrollment. In-person appointments were 81.6%. Patients with a mRS of < 2 is 47.9% at 90 days. The mortality rate among patients participating in the program was 0.9% ( figure 3 ). Barriers identified implementing a transitional post-stroke care model included lack of manpower, transportation issues for patients, difficulties scheduling appointments within 14 days of discharge, and challenges obtaining records from outside facilities. Conclusion: Enrollment in a transitional stroke care model has been unexpectedly challenging due to 2-day post discharge phone calls and 14-day appointment criteria. Although those enrolled have improved functional status at 90 days, it may not have an impact on 30- or 90-day readmissions. However, there are significant benefits related to the coordination of post-stroke care (i.e., therapy referrals). Additionally, there is a downward trend in mortality rates ( figure 3 ).