Wake Forest Baptist Medical Center’s transitional stroke clinic, developed to provide standardized care for stroke patients discharged to home, resulted in a 48% lower risk of 30-day readmissions among patients who made just one visit to the clinic.

  • The clinic is run by nurse practitioners who see patients within 14 days of discharge and assess them for medical, cognitive, and psychosocial needs, conduct medication reconciliation, and screen for caregiver burnout.
  • Patients attend the clinic in addition to going to their regular follow-up visits with the neurology clinic, their primary care providers, and therapy sessions.
  • The model also includes follow-up phone calls by an RN within two days of discharge to ensure patients have filled their prescriptions and know how to take their medication, if any equipment has arrived, and to continue the education started in the hospital.

Patients who attended a transitional stroke clinic staffed by nurse practitioners at Wake Forest Baptist Medical Center had a 48% lower risk of a 30-day readmission compared to patients who did not attend the clinic, according to a study by physicians and nurse practitioners at the Winston-Salem, NC, hospital.

The study evaluated 510 stroke or transient ischemic attack patients who had been discharged to home during a three-year period. In addition to the post-acute visits to the stroke clinic, the patients received follow-up calls after discharge. The transitional stroke clinic opened in October 2012 in the hospital and is run by nurse practitioners Sarah Lycan, MSN, NP, and Christina Condon, MSN, NP.

The study found that patients who received the follow-up telephone call and did not come to the clinic did not have lower readmission rates, but patients who received a phone call were more likely to come to the clinic than those who did not.

The transitional stroke clinic doesn’t replace follow-up visits with the hospital neurology team, post-discharge appointments with patients’ primary care physicians, or therapy sessions, Lycan says. “We want to see patients as soon as possible after discharge so we can help them understand their treatment plans and make sure they have all the services they need to help them get on the road to recovery,” she adds.

The Wake Forest Baptist transitional care model was developed to provide standardized care for high-risk stroke patients being discharged to home, to coordinate care between the neurologists, cardiologists, primary care physicians, and other clinicians treating the patients, and to connect patients and family members to the community resources they need, Lycan says.

“Before the clinic opened, we had detailed protocols on the management of stroke on the hospital side, but once patients went home, there was no standard follow-up and no standard care model for post-acute stroke care,” Lycan says.

In Phase I of the clinic development, Lycan and Condon made follow-up calls within seven days of discharge only to the stroke patients who were at highest risk and saw them in the clinic within two to four weeks. High-risk patients included those who experienced acute renal failure while in the hospital, those with a history of heart failure, patients who had two or more ED visits or hospital admissions within a year, patients on anticoagulant therapy, and those with multiple social issues or little support at home.

In Phase II, a registered nurse was added to the staff and began making follow-up calls to all stroke patients within two days of discharge. Having a nurse make the phone calls freed Lycan and Condon to see patients within seven to 14 days.

During the follow-up phone calls, the nurse asks patients if they have filled their prescriptions, if understand their medication regimen and are following it, and screens for symptoms that could indicate a problem.

The nurse checks to see that any equipment or services, such as home health, are in place and make sure patients are attending outpatient therapy if it is prescribed and that they have a follow-up visit with their primary care provider. If patients have questions about medication or symptoms, the nurse can forward the call to a nurse practitioner.

Shortly after they began seeing patients, the nurse practitioners developed a structured screening process for visits, Lycan says. “We saw common themes and geared the visits to emphasize the key issues that patients had in common. We look at each individual patient’s highest needs and adapt the visit to meet those needs,” she says.

The clinic screens patients for medical issues as well as cognitive and physical deficits, including any new issues that may have developed since discharge, and stroke symptoms and progression. The nurse practitioners talk to the patient about comorbidities, risk factors for stroke, and the importance of monitoring blood pressure and blood sugar levels. They conduct medication reconciliation and make sure the patients understand any medication change.

“We talk about the importance of medication adherence and check for medication side effects. We look for cognitive issues that could affect a patient’s ability to remember to take their medicine and work on strategies to overcome the problem,” Lycan says. The nurses share the information with the patients’ primary care physicians and other clinicians who are providing care.

The nurse practitioners assess patients’ social needs and psychological issues such as depression, and screen for deficits such as the inability to walk, continuing weaknesses, or speech problems. They also screen caregivers for burnout and depression.

The program is being expanded to include community services and phone calls 30 and 60 days after discharge, Lycan says.

“Our next step is to incorporate an electronic care plan for each patient into our program and to make it available to the primary care physicians, specialists, home health, and outpatient therapy so everybody is on the same page,” she says.

Wake Forest Baptist Healthcare is participating in the Comprehensive Post-Acute Stroke Services (COMPASS) study to investigate post-acute stroke models in hospitals throughout North Carolina.