Background: Stroke patients are at a significant risk of inconsistent care and adverse events after discharge from the hospital. Follow-up contact has been thought to facilitate continuity and compliance with the discharge plan of care, but evidence is lacking as to optimal timing and intensity of follow-up. Our organization established a stroke clinic in 2009 with a schedule for follow up at 30 days, 90 days, and 1 year. In 2014, in effort to increase follow-up volume, the process was amended to ensure that appointments were made prior to discharge.
Method: Analysis of 2014 follow-up appointments was conducted by the Stroke Clinic Process Improvement Group. The appointment order was added to the stroke admission order sets so that appointments would display on discharge paperwork.
Discussion: There was a 55% increase in patients who followed-up from 2013 to 2014. This improvement continued through 2015. However, despite the successful increase in appointments, the clinic reported an atypical no-show rate of 29% for 2014 and 40% for 2015, a loss of $51,165, in addition to the cost of provider down-time. A deeper analysis of appointment type revealed a significant drop in 1-year visits. Since the data also revealed that most patient visits are at either 30-days, or 30 and 90-days, our process was amended once again to exclude 1-year visits. In addition, the follow-up appointments are now ordered 48 hours prior to discharge, ensuring appointments continue to display on discharge paperwork.
Conclusion: Process improvements sometimes result in unexpected downstream effects. We determined that the increase in follow-up appointments did not justify the financial and productivity loss to the clinic. Monitoring of no-show data and stroke clinic volume will be essential as this stroke clinic process evolves. Until we find a way to make patients come for stroke clinic follow-up visits, we will continue to be challenged to find a way to support them through their post-stroke recovery.