Abstract W P278: Defining the Role of the Nurse in Transitions of Care Within a Comprehensive Stroke Center (CSC)
Transitions in care are a top priority for the US health care system as well as a core component of the CSC standards. Nurses are key in facilitating care from admission to discharge ensuring successful transitions through a stroke health challenge. Impetus to examine hospital readmission rates has been heightened by public reporting and potential CMS financial penalities.
The purpose of this presentation is to describe an interdisciplinary approach in planning care transitions supporting discharge. Our experience as a recently certified CSC identified opportunities for improvement in stroke care transitions.
A Stroke Continum Subgroup was formed including key stakeholders in partnering rehab facilities, inpatient rehab, home care, and stroke inpatient units to examine care transitions. Focused efforts evaluated discharge resources emphasizing patient and caregiver assessment, caregiver preparedness, and educational materials. Areas developed to support transitions included: standard caregiver resources including respite needs, daily discharge huddle identifying home needs and 7-day phone follow-up process. Metrics tracked included length of stay, discharge disposition, number of patients surveyed, number of caregivers provided educational materials and readmissions.
Developing interdisciplinary relationships promoted improvements in communication that lead to improved patient transitions related to follow up care, medication reconciliation and sharing of clinical information to promote continuity of care. At one year, 75% of patients received a structured post-discharge phone call which continues to identify opportunities to assist with scheduling follow up care, support early recognition of post stroke depression and ensure caregivers utilize respite resources. Our 30 day readmission rates in our ischemic stroke patients decreased to 7%, an overall 5% reduction from previous year.
Assessment of patient and caregiver needs after discharge can be difficult and requires a coordinated multidisciplinary effort with multi-prong interventions. Development of a Stroke Care Continum team allowed the CNS and Stroke Director to work with both inpatient and outpatient stakeholders.
Author Disclosures: C. Mathiesen: None. E.M. Conahan: None.
- © 2014 by American Heart Association, Inc.