Abstract TP377: Stroke Navigator Program Supports Community Reintegration and Decreases Readmissions

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Background: Navigating the healthcare system is complex. We believe successful community reintegration for stroke patients requires: 1) overcoming barriers; 2) educating on disease process, risks, medications, and when to seek medical attention; 3) integrating patient support; 4) promoting rehabilitation; and 5) coordinating follow-up care.Purpose: We sought to establish the impact value of a Stroke Navigator Program (SNP) in supporting the transition from acute care through community reintegration. Measures utilized to demonstrate program efficacy included patient recall of key information, adherence to medications and appointments, and incidence of hospital readmission.Methods: SNP patients were enrolled during initial hospitalization. An assessment was performed to determine baseline knowledge in stroke etiology, symptoms, and medication use; support structures; individual goals; and readmission risk. Follow-up contacts for further assessment and evaluation of patient progress were conducted. These included access to rehabilitation services and completion of medical follow-up appointments. Contacts were planned, managed and documented using workflow management software.Results: Between January 1, 2015 and December 31, 2016, 463 patients were enrolled. Interviews were completed with patients, spouses or significant others, family members or caregivers, and others at specific intervals after hospital discharge. A majority of respondents verbalized basic understanding of the stroke diagnosis, with similar results reported in the ability to obtain medications and with medication adherence. Assessment of initial, post-discharge comprehension demonstrated inconsistent recall of specific stroke symptoms, individual risk factors, and when to seek emergency medical assistance. The 30-day, all-cause hospital readmission rate for enrolled patients was 2.6%, compared to an overall stroke patient readmission rate of 6.3% for the period.Conclusion: Participation in the SNP correlated with fewer hospital readmissions while reinforcing and validating patient knowledge in areas that can impede successful community reintegration.

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