What question did this study set out to answer?

To evaluate the feasibility and outcomes of a nurse-led transitional stroke program for veterans post-discharge.

February 2, 2026Stroke

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

Q: What are the key findings of this study?

Patients enrolled in the nurse-led transitional stroke program showed improved functional status with 47.9% achieving mRS < 2 at 90 days, despite enrollment challenges.

Q: What does this research mean for the field?

Patients enrolled in the nurse-led transitional stroke program showed improved functional status with 47.9% achieving mRS < 2 at 90 days, despite enrollment challenges. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

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Key result

Nurse-led stroke program linked to ~48% of patients achieving mRS < 2 at 90 days.

Why the study?

Post-stroke transitional care is fragmented and unorganized, contributing to higher readmissions, poor outcomes, and caregiver burden, prompting evaluation of a nurse-led transitional care model.

Is a nurse-led transitional stroke program feasible for veterans discharged home after acute stroke/TIA?

Key Points

To evaluate the feasibility and outcomes of a nurse-led transitional stroke program for veterans post-discharge.
Invited stroke/TIA veterans from local VA and non-VA facilities to participate.
Conducted initial and follow-up phone calls to assess patient status.
Used modified Rankin Scale (mRS) to evaluate functional outcomes at 90 days.
326 veterans enrolled in the program with over half from non-VA facilities.
Average days from discharge to outpatient follow-up was 27.4.
47.9% achieved mRS of <2 at 90 days, indicating improved functional status.
Mortality rate among participants was 0.9%.

Structured PICO

Is a nurse-led transitional stroke program feasible for veterans discharged home after acute stroke/TIA?

Population

326 veterans discharged home with a diagnosis of acute stroke/TIA from local VA or surrounding non-VA facilities, mean age 69.9, 93.3% male.

Intervention

90-day Nurse-Led Transitional Stroke Program (NLTSP) including a 2-day post-stroke call, outpatient follow-up visit with a stroke provider, and a 90-day post-stroke call.

Outcome

Feasibility of implementing the Nurse-Led Transitional Stroke Program

A nurse-led transitional stroke program for veterans is feasible and may improve care coordination and functional status, though early appointment scheduling and care fragmentation remain significant barriers.

Limitations

lack of manpower
transportation issues for patients
difficulties scheduling appointments within 14 days of discharge
challenges obtaining records from outside facilities

Discussion

No takes yet. Share an insight, caveat, or question.

Implication

May support feasibility of nurse-led transitional care in veterans; leaves open efficacy versus usual care in prospective trials.

Cite This Study

JENKINS et al. (2026) studied this question. Patients enrolled in the nurse-led transitional stroke program showed improved functional status with 47.9% achieving mRS < 2 at 90 days, despite enrollment challenges.

synapsesocial.com/papers/6980fd3cc1c9540dea80f07c https://doi.org/10.1161/str.57.suppl_1.wp323

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

Key Points

Structured PICO

Limitations

Discussion

Implication

Cite This Study

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

Key Points

Structured PICO

Limitations

Discussion

Implication

Cite This Study

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