What question did this study set out to answer?

This initiative aims to evaluate the impact of a Nurse Navigator follow-up model on patient outcomes after hospital discharge.

February 2, 2026Stroke

Abstract WP312: Navigating the Road to Recovery: Guiding Patients Beyond Discharge: A 90-Day Post-Discharge Model

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This initiative aims to evaluate the impact of a Nurse Navigator follow-up model on patient outcomes after hospital discharge.
Implemented a structured follow-up model involving Nurse Navigators.
Conducted initial phone assessment within 72 hours post-discharge.
Scheduled multi-touchpoint check-ins at 7, 21, 30, and 90 days.
Customized interventions based on patients' risk factors and needs.
Coordinated with rehabilitation facilities and primary care providers.
70% of patients were reached by Nurse Navigators at 21 days post-stroke.
94% of stroke patients attended their scheduled 30-day follow-up visits.
Success in ensuring documented visits with primary care providers for 94% of patients before 30-day follow-up.
Demonstrated strong patient engagement and care coordination during the 90-day post-discharge period.

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Implication

Quality improvement initiative demonstrates effective post-discharge care coordination, reducing readmissions in stroke patients, indicating the model's potential value.

Cite This Study

Amy Wildasin (2026) studied this question.

synapsesocial.com/papers/6980fbbec1c9540dea80d921 https://doi.org/10.1161/str.57.suppl_1.wp312

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Implication

Quality improvement initiative demonstrates effective post-discharge care coordination, reducing readmissions in stroke patients, indicating the model's potential value.

Abstract WP312: Navigating the Road to Recovery: Guiding Patients Beyond Discharge: A 90-Day Post-Discharge Model

Key Points

Discussion

Implication

Cite This Study

Abstract WP312: Navigating the Road to Recovery: Guiding Patients Beyond Discharge: A 90-Day Post-Discharge Model

Key Points

Discussion

Implication

Cite This Study

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