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Introduction: Implementing traditional hub and spoke models of tele-stroke care consisting of an urgent evaluation for acute therapy decision making has been shown to improve care delivery to the acute ischemic stroke population. However, outcomes of patients retained in spoke facilities after acute evaluation are inequitable with longer inpatient length of stay and higher mortality despite lower prevalence of severe stroke and large vessel occlusion as compared to patients treated at the hub. We analyzed the effect of continued involvement of a vascular neurologist in the care of all stroke patients via tele-stroke rounds during the inpatient stay at a spoke facility.Methods: The stroke alert protocol in the spoke facility was revised to include calls to the tele-stroke service for all patients presenting to the ED with stroke symptoms regardless of severity or time. A tele-stroke evaluation by a vascular neurologist from the hub hospital occurred for all patients including both acute evaluation and stroke etiology work-up initiated immediately by the tele-stroke provider. Inpatient tele-stroke rounds then occurred on all patients with at least one further telemedicine evaluation to review findings and make final recommendations. Outcomes were compared for three months prior to starting telestroke follow-up and three months after instituting this program.Results: A total of 143 patients (91 pre implementation and 52 post implementation) were included. The results are summarized in the table. In the three months after starting tele-stroke follow-up by vascular neurologists length of stay, 30 day mortality and readmissions were reduced. Utilization of IV tPA increased from 3.3% of all stroke patients to 10%.Conclusion: These results indicate that implementation of a remote telemedicine stroke service to manage patients beyond the initial acute evaluation in a spoke facility is feasible and can positively influence patient outcomes.