Introduction: In Wisconsin (WI), approximately 75% of those with a principal diagnosis of stroke have pre-existing hypertension. Managing hypertension after discharge is key in preventing a secondary stroke. Furthermore, transition of care to home for many stroke patients is suboptimal. Evidence indicates that 30-day all-cause readmission of stroke patients is 17.4% nationally. From 2023 to 2025, the WI partnered with a Mobile Integrated Health (MIH) team at an emergency medical service (EMS) agency and a hospital to improve follow-up care and coordination after an acute stroke hospitalization. Methods: Workflows, eligibility criteria, and data tracking tools were established. Patients discharged home with a final diagnosis of hemorrhagic or ischemic stroke were eligible for an MIH visit . The MIH team engaged the patient within 30-days post-discharge. After a completed visit, the MIH team sent a summary form via secure email to the referring hospital. This form mirrored post-discharge data metrics in Get With The Guidelines® (GWTG). Upon receiving the summary form, the hospital entered the data into the local GWTG database, which was then analyzed using descriptive statistics. Results: In total, 72 stroke patients received a home visit from the MIH team with data entry in GWTG. The MIH project data was compared to 12 WI hospitals entering into the GWTG Post-Discharge tab during the same timeframe. Comparison hospitals may or may not have MIH activity. Results showed: MIH hospital outperforms in 30-day readmission, blood pressure (BP) monitoring by patient, and appointment scheduled prior to discharge. MIH hospital underperforms in falls reported by patient , ED visits, and tobacco use. In addition, there were improvements from year 1 to 2 in appointment scheduled prior to discharge and BP reported . Conclusions: MIH programs can enhance post-discharge outcomes by reinforcing education, ensuring follow-up care, and identifying gaps in resource utilization. Many factors influenced the data. First, the population in the MIH program was from an urban environment with more proximate post-discharge resources. All WI hospitals do not share this setting. Second, MIH data collection involves an in-person home visit. Data collection from comparison hospitals mostly occurred via a phone call or chart review. The MIH method facilitates an environment where more truthful disclosures may result. MIH partnerships should be explored to optimize transitions of care.
Attar et al. (Thu,) studied this question.