Abstract WP369: Doctorate of Nursing Practice-led Transitions of Care Model for Stroke and Transient Ischemic Attack

Abstract

Background and Purpose: The chances of experiencing a second event are significantly increased in those with recent stroke or transient ischemic attack (TIA). Gaps in care due to the movement of patients between health settings and/or practitioners, also known as transitions of care (TOC), may contribute to secondary events. The impact of TOC on stroke/TIA outcomes has not been thoroughly examined. The Doctorate of Nursing Practice (DNP) is a relatively new role within the nursing profession that provides advanced practice nursing care, leadership and research expertise. As the first phase of a long term goal to evaluate a DNP-led TOC model specific to the stroke/TIA population in Southeastern Arizona, the purpose of this study was to identify the essential elements of a model specific for stroke/TIA using data from one urban primary stroke center. Methods: 1) Existing TOC models such as PRISMA, Hospital to Home, and STEPS were identified with applicability to the stroke/TIA patient. 2) Get With The Guidelines [GWTG®]-stroke database from a primary stroke center located in an urban setting in Southern Arizona was used to identify patient demographics and the essential elements that best reflect TOC. Results: We found 1) the Care Transitions Intervention model best suits a DNP-led TOC model for stroke-TIA. Key elements of this model include an interdisciplinary team approach utilizing case-management strategies, discharge planning, and patient self-management education. In addition, the advanced practice nurse has been found to be most successful in leading TOC models aimed at reducing readmissions. 2) Key outcome variables in a stroke specific TOC model include frequency of admission/readmission, patient demographics, prior hospitalizations, length of stay, discharge disposition, presence of stroke risk factors and urban vs. rural settings. 3) Post-discharge phone interviews may be needed to explore gaps in care not captured in GWTG. Conclusions: While TOC models have been described for other diagnoses, models for stroke/TIA are lacking. The use of the Care Transitions Intervention model for stroke/TIA could yield important reductions in the burden, morbidity, and mortality of stroke/TIA in Southeastern Arizona and thus, deserves further study.