Abstract WP323: Bridging The Gap Between Acute Care and Public Health
Background: The WHO estimates that only 50% of patients with chronic illness adhere to treatment recommendations. The Affordable Care Act targets hospital readmission rates as cost savings opportunities. Readmission rates reported in the literature range from 6-33%. Transitional care programs have been shown to improve patient outcomes.
Purpose: To reduce readmission and recurrent stroke, the Stroke Patient Education and Navigation (SPEN) Project sought to enhance the continuum of care post discharge by forming collaboration between the University of Louisville Stroke Center (UL), Taylor Regional Hospital (TRH) and the Department for Public Health. Primary outcomes of this three-year project were hospital readmission, medication adherence, utilization of community resources, and National Quality Forum (NQF) 18: blood pressure less than 140/90.
Methods: Stroke patients transferred from TRH to UL discharged home from October 2013 to January 2015 were invited to participate. After discharge nurses made 3 home visits at 2 weeks, 3 months, and 6 months to assess outcomes, biometrics, and blood pressure self-management. A follow up phone call was made at one year.
Results: 44 patients participated (mean age 70, 28 male, 16 female). 32/44 (73%) completed all 3 visits. 36/44 (82%) with medication adherence. 2/44 (5%) readmitted within 30 days (1 with TIA and 1 with pneumonia). 2/24 (8%) participated in a community resource (smoking cessation program and diabetes classes). Reasons for not using community resources were lack of transportation and “not needed”. Results of NQF 18 goals achieved: 29/44 (66%) at visit 1 and 12/28 (43%) for all 3 visits. At one-year post discharge 10 patients had been readmitted, 3 for vascular events (1 TIA, 1 MI, 1 HTN). Cost of project per patient was $306.62.
Conclusions: the SPEN project achieved low 30-day readmission rate and positive medication compliance, but did not achieve utilization of community resources or satisfactory NQF 18 results. Future projects should consider methods to improve resource utilization and cost effective methods of follow-up, such as multiple telephone or telehealth interactions.
Author Disclosures: K.D. Moore: None. B. Bobo: None. P. Rock: None. E. Wise: None.
- © 2016 by American Heart Association, Inc.