Reducing Readmissions in Stroke Patients With a Structured Nurse Practitioner (NP)/RN Follow-up Program

Background: Our aim was to determine whether a structured stroke follow-up clinic (SFC) could reduce 30-day and 90-day readmission rates for patients discharged home with ischemic/hemorrhagic stroke or TIA.Methods: Prior to discharge, NPs identified patients at high risk for readmission, an RN performed follow-up phone calls, and the clinic visit included a standardized and comprehensive stroke nurse practitioner (NPs) assessment. Phase 1 of the SFC (10/2012) consisted of phone calls within 7 days of discharge, and 2 NPs seeing patients within 2 weeks of discharge, which focused on education, prevention, recovery and evaluation for complications. Phase 2 (9/2014) expanded to an RN calling 90% of patients discharged home within 2 days, and any issues identified were managed by NPs before the SFC visit. Demographics, medical history, and processes of care were entered into a REDcap database. Differences in these factors and readmission across the 2 phases of the SFC were assessed. Multivariate logistic regression models for 30-day and 90-day readmissions were performed with adjustment for NIHSS and hospitalizations prior to the index stroke.Results: We analyzed 280 consecutive patients through 4/2015. Mean age 66.1 y ± 14.5, 51% women, median NIHSS 3 (IQR 1-5), 34% prior stroke/TIA, and 20% with prior hospitalizations. From phase I to phase 2, days from discharge to SFC decreased, and 90-day readmissions decreased (table). Patients readmitted within 30 days had lower SFC show rates (60% vs 82.9% not readmitted; p=0.006), as well as 90-days (69% vs 83% not readmitted; p=0.034). Multivariable modeling after adjustment for prior hospitalizations, prior stroke, and NIHSS showed that SFC show rate was associated with a 74% reduction in 30-day readmission (OR 0.26; 95% CI 0.11-0.66) and a 63% reduction in 90-day readmission (OR 0.37; 0.15-0.89).Conclusions: Stroke patients’ show rate for this SFC was independently associated with reduced 30-day and 90-day readmission. ![][1] [1]: /embed/graphic-1.gif