Abstract 3839: Obtaining Systematic Neurologic Follow-up after Stroke Discharge - Is it possible?

Abstract

Background: Systematic follow-up after hospital discharge for stroke is an important part of optimizing transitions of care, although its feasibility is not well known. Advances in healthcare technology provide a means to accomplish this. Methods: The Cleveland Clinic Neurological Institute implemented a technology-based follow-up system for patients hospitalized on the Stroke service. The system includes two major components to assist with follow-up: an electronic health record-based method for physicians to order a 30 day follow-up appointment electronically during patients’ admissions (similar to ordering a lab test), and system-generated messages that are sent to a nursing pool in cases where patients either do not have a scheduled appointment or their appointment was not kept. These activities are also monitored with standard reports. In addition, structured templates were developed to allow discrete capture of clinical data at the time of follow-up. Data on stroke patients from the first 15 months were analyzed after excluding patients who died prior to discharge or were discharged to hospice care. Results: Of the 574 patients in the study, from 3/2010 - 6/2011, 42.9% were discharged to home and 57.1% were discharged to other facilities. The rate of scheduled follow-up appointments within 45 days of discharge was 31.6% at baseline, although many of those were scheduled post-discharge. Successfully completed follow-up appointments within 45 days occurred in 10.5% at baseline and increased steadily over the 15 month period to 58.1% in June 2011 (see Table). Patients discharged to home had higher rates of completed follow-up compared to patients discharged to other facilities (63.6% vs 33.1%, p<0.01). Conclusion: Implementation of systematic, electronic processes for establishing post discharge follow-up in stroke patients is associated with a progressive increase in rate of successfully completed appointments. There were lower rates of successful follow-up in patients not discharged to home, and coordinated efforts across facilities may be required for full implementation of follow-up care. Informatics technology will play an increasingly important role in systems-based care for the stroke patient population.