Background: Stroke nurse navigator (SNN), modeled after other proven disease specific navigator roles, may be an effective way to positively impact patient experience and improve outcomes. There is a paucity of data on the feasibility and effectiveness of stroke nurse navigator role. We want to present descriptive analysis of first six months experience with SNN at our Comprehensive Stroke Center (CSC).
Methods: The SNN was implemented in January 2017. Population includes patients discharging home and or discharged to rehab or skilled nursing facility with complex follow up needs. The SNN also follows up on an as-needed basis for issues such as extended cardiac monitoring, imaging and anticoagulation. Seven day phone follow up is performed for home discharges and 90 day phone follow up for selected patients using a standardized questionnaire developed collaboratively with stroke experts spanning the continuum of patient care. Other tools utilized by the SNN include use of EHR (electronic health record) inbox for streamlined communication between SNN and stroke clinic administration staff as well as EHR template letters with a standard risk factor assessment and education. Shared patient lists, and a database for long term patient outcome tracking were also used.
Result: Information collected at the seven day phone call includes review of symptoms, review of medications, follow up plan, lifestyle modification, stroke signs and symptoms, patient experience and at 90 days also includes modified Rankin Scale (mRS). Between February and June, 118 patients were seen by SNN prior to discharge, 86 of which were home discharges and 48% of all home discharges during the same period. 85% of all home discharges were successfully reached within seven days by phone to complete the post-discharge assessment. There have been instances of new symptom recognition by SNN during follow up that prompted some emergent readmissions.
Conclusion: In conclusion, the role of SNN is feasible at a CSC and early data suggests improved patient experience, education, and follow up. Data collection requires manual maintenance of patient lists and a large database separate from the EHR. Further research is needed on standardized tools for management of long term stroke patient follow up.