Transitions of care for stroke and TIA

Abstract

Purpose The purpose of this study was to identify elements of a stroke population that may affect transitions of care (TOC). Data sources A retrospective analysis of the demographic characteristics of patients from an urban primary stroke center with an admitting diagnosis of transient ischemic attack, acute ischemic stroke, subarachnoid hemorrhage, or intracerebral hemorrhage was performed over an 8‐month period (N = 276). A subset of this patient sample participated in a telephone survey 1 month after discharge. Conclusion Hospital length of stay, age, insurance status, discharge disposition, comorbidities, and readmission rates were identified as important elements affecting TOC for stroke and TIA. Information from patient surveys indicated that emotional health, follow‐up with care providers, stroke education, and point of contact are important elements during the transition periods after stroke and TIA. Implications for practice Both providers and patients should inform the development of a comprehensive TOC program that spans in‐hospital to multiple care settings, including the home, which is essential. The advanced practice nurse is ideally suited to successfully lead these programs.

From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke

“…Beneficial targeted interventions include programs for: 1) medication management, 20 2) fall prevention 21 3) patient and caregiver education, 4) facilitation of communication with providers in community, 22 5) pre-discharge home evaluations, and 6) self-management programs. 3,21,[23][24][25] While models of discharge planning vary in structure and focus, they include common characteristics, such as: 1) use of a multidisciplinary team approach, [26][27][28][29] 2) initiation at time of admission, 30 3) engagement of the patient and care partners throughout the process, 27,31,32 and 4) high-quality communications. 32,33 Structured discharge planning is the aim of the TOC model and important for successful transition home after rehabilitation.…”

“…34 These community health workers act as accountable receivers in the TOC framework facilitating appropriate action by identifying barriers to patient engagement and assisting the patient and caregiver with access to community resources. 34 Additionally, the emotional health 25 and engagement of stroke survivors 35 and their caregivers 34 can also influence transitions of care, thus making them significant accountable receivers of information in the TOC model, especially at the discharge to home transition.…”

Impact of NP follow-up calls on reducing 30-day readmissions in patients with stroke

“…such as infections, and recurrent stroke, which are highly associated with increased mortality, healthcare costs, and decreased quality of life. [3][4][5][6][7][8][9][10] Understanding the most common causes of 30-day readmissions can assist in the development of interventions to target those causes. In a systematic review and retrospective claims analysis, recurrent stroke was the most common cause of 30-day readmissions in patients with ischemic stroke.…”

“…Readmissions within the first 30 days after hospital discharge can result from a progression of the patient's disease, inadequate care of the underlying problem, or inadequate coordination of care after discharge 2. Patients with stroke have been identified as a group at risk for readmissions due to complications of stroke, such as infections, and recurrent stroke, which are highly associated with increased mortality, healthcare costs, and decreased quality of life 3-10…”