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Focus on Transitional Care Reduces Hospital Readmissions in Stroke Patients

A transitional stroke clinic developed by doctors and nurse practitioners at Wake Forest Baptist Medical Center reduced 30-day readmission rates by 48 percent, according to a study published in the April 28 online issue of the journal Stroke.

The study’s goal was to determine if a structured transitional stroke clinic led by nurse practioners could reduce 30-day and 90-day hospital readmission rates.

“The needs of patients discharged directly home after suffering a stroke are often complex,” said Cheryl Bushnell, M.D., director of the Stroke Center at Wake Forest Baptist and lead author of the study.

“Patients are faced with physical and cognitive limitations, complex medication regimens, new diagnoses of chronic conditions and lack of social support. These barriers challenge independence and stroke recovery and leave patients at high risk for readmissions.”

The study evaluated 510 stroke or transient ischemic attack patients who had been discharged to their homes over a three-year period. The Wake Forest Baptist transitional care model included follow-up phone calls within a week of discharge and follow-up clinic visits within two to four weeks of discharge.

The researchers found that a visit to the stroke clinic was associated with a 48 percent lower risk of 30-day readmissions compared to patients who did not attend the follow-up clinic visit. A clinic visit did not affect 90-day readmission rates. A limitation of the study was that only readmissions at Wake Forest Baptist were included.

“A lot of stroke programs are doing follow-up phone calls to patients, but our data shows that phone calls alone are not good enough to reduce readmissions,” Bushnell said. “It is really important for patients to be engaged in their own stroke recovery, and part of that involves coming to clinic and making sure they get all the services they need.”

Bushnell also said that primary care doctors caring for stroke patients should be alert to changes that are hallmarks of stroke: patients not thinking as clearly as they used to, memory problems, limited ability to use their hands or overall mobility issues, as well as depression and social isolation.

“We are at the forefront of a trend that really emphasizes the initial transition phase in post-stroke care,” Bushnell said. “The next steps include expanding our model to include community services and individualized electronic-care plans.”

A clinical trial is now being implemented across the state of North Carolina to determine if this model of care will improve stroke patients’ functional status and reduce caregiver burden 90 days post-stroke, Bushnell said. The trial is funded by the Patient-Centered Outcomes Research Institute.

Co-authors are: Christina Condon, M.S.N., N.P., Sarah Lycan, M.S.N., N.P., and Pamela Duncan, Ph.D., of Wake Forest Baptist. 

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