Abstract NS4: Stroke Discharge Unit Bridging Education and Transitional Care

Background: Effective discharge planning is essential for stroke patients to ensure safe transitions from hospital to home. Stroke patients often face challenges during hospital discharge due to lack of standardized and personalized education, especially those with cognitive or communication impairments. These gaps can lead to poor medication adherence, missed follow-ups, and increased readmissions. Purpose: To improve outcomes, a Stroke Discharge Unit was created to deliver tailored education, medication reconciliation, and coordinated follow-up care. The goal was to enhance patient understanding, compliance, and satisfaction. Methods: The discharge process included four components: Individualized Education: Stroke cause, treatment, risk factors, and lifestyle changes were explained using Joint Commission standards. Patients and caregivers received written and verbal instructions, including BEFAST signs and EMS activation. Risk factor modifications were personalized. Follow-Up Coordination: The Stroke Nurse verified appointments with PCPs and stroke clinics were confirmed or scheduled within 7–14 days. Referrals were made to the Transitions of Care Clinic when needed. Meds to Beds: A 30-day supply of medications was delivered before discharge, with pharmacist counseling provided to all patients, including uninsured. Perception of Care Survey: A discharge survey assessed patients’ understanding of their diagnosis, treatment, stroke signs and symptoms, and emergency response readiness. It evaluated whether the care received met their needs and provided actionable feedback for continuous improvement. Results: The data has shown a reduction in readmission rates from 1.636 in 2024 to 0.964 2025 YTD. Enhanced patient satisfaction was measured by stroke perception of care survey with improved satisfaction rates from 84% for 2024 to 91% in 2025 YTD. Stroke education compliance was measured by Get With The Guidelines- Stroke Quality Measures. Individualized stroke education improved from 88% in 2024 to 95% in 2025 YTD. The Meds to Beds program addressed barriers related to insurance and transportation which lead to improved medication compliance. Conclusion: A dedicated Stroke Discharge Unit enhances care transitions, education, and medication adherence. This model can serve as a framework for other institutions seeking to reduce stroke-related readmissions and improve patient-centered care.