Emerging Post-Hospital Models of Care: A Primer for Stroke Center Leaders

After discharge, stroke survivors are at high risk for secondary stroke as well as readmission to a hospital. While stroke center certification standards emphasize preparing patients and caregivers for discharge, patients discharged to home may experience delays in seeing a community provider and report inadequate preparation for discharge. Several models suggest inpatient stroke programs are assuming additional roles and responsibilities in the management of patients after discharge. Models such as a stroke nurse navigator, post-stroke clinics and other interdisciplinary supported discharge programs may address gaps in care after discharge. Even with this evidence, stroke leaders should evaluate their own patient outcomes to understand their needs and plan services accordingly. Strategies to evaluate discharge outcomes and advocate for services are discussed.