Background: Post stroke care is complex for patients and families. A stroke nurse navigator is able to improve continuity through the transition from inpatient to outpatient realms promoting follow up, compliance, and improved patient satisfaction.
Objective: To highlight the need and efficacy of a stroke nurse navigator program for certified stroke centers.
Methods: We retrospectively reviewed all patient encounters from March 2017-July 2017 performed by our navigator. Approximately 1000 stroke patients are seen annually at our institution. The navigator meets with the patients and families within 24 to 48 hours prior to discharge and establishes contact. A series of calls are made to patients including one at 7-14 days, 30 days, 90 days (MRS) and one year post discharge. Referrals, patient acuity levels based on needs (low, medium, high), urgent needs, and medical inquiries are tracked after each of these calls. All calls and referrals were analyzed.
Results: During the four month data collection period, 202 stroke patients were called and approximately 83% were evaluated in-house prior to discharge. A total of 286 calls were completed as follows: 67% within 7-14 days, 17% within 20-45 and 16% within 90 days. Of the 202 patients called, 78% were designated as low, 19% as medium, and 3% as high complexity after the initial call. A total of 46 referrals were made including 6 for medical evaluation in the clinic, 4 to social work; 4 to local support groups; 1 each to our community liaison, marketing group and behavioral health; and 23 patients were identified as candidates for an active stroke research study. Assistance with FMLA forms and disability claims was provided to 6 patients.
Conclusion: Despite over two-thirds of patients being designated as low complexity, 1 in 5 patients required further assistance or a referral after discharge. The stroke nurse navigator role provides a much needed link between the inpatient and outpatient setting and is an integral part of the stroke program.