Title : Improving stroke patient outcomes through care coordination and management of the healthcare transition
As a team the Stroke Navigators (SN) work to improve stroke patient outcomes and minimize hospital readmissions. The SN has a multifaceted approach to eliminate disjointed care during hospitalization through transition into the outpatient setting. SNs work as part of an interprofessional team by communicating with providers, specialists, case managers and therapy to help identify patients getting the right care, at the right time, in the right setting. Providing individualized bedside education to the patient and family, the SNs meet the patients' needs of understanding their stroke risk factors and recovery plan of care. Once discharged from the acute setting SNs attempt to reach patients post discharge at the 48hr and 30-day mark to reiterate education, ensure no barriers to plan of care have been encountered and to address any questions or concerns from the patient and family. SNs also ensure appropriate follow up with Stroke Clinic, PCP (Primary Care Provider) and/or Transitions Clinic are scheduled, and patient is aware. At the time of discharge, the SN sends a referral to the mobile integrated health team to assist in the transition of care following discharge. In the 4th quarter of 2022, readmission numbers no longer met our O/E goals that were previously reduced from 2021. In this presentation, the audience will learn how the SNs adjusted workflow to meet the identified gaps in care for the stoke patients. The primary objective is to decrease hospital readmissions; the secondary objective is to increase utilization of community resources available to patients. In the beginning of 2023, the SNs adjusted their inpatient coverage allowing for bedside rounding to increase throughout the patient's acute stay. This allows for establishing relationships with patients and family and an increase in individualized bedside education sessions. The SNs goal is for the patient and family to recognize the SN as a resource, as needed, once discharged from the hospital. Previously, the SNs referred patients from only one local county to the Mobile Integrated Health (MIH) program. In March 2023 the MIH program expanded to cover multiple counties to include more of the stroke patient population. Along with the MIH program expanding, those patients with complex medical needs are eligible to be followed by the transition care services. The SN has put an increased emphasis on referring appropriate patients to this service. Through these countermeasures the SNs strive to meet the readmission goal of O/E 1.032, with a target condition of 4 or less readmissions per month. Through this presentation the SN will share with the audience the value of having dedicated nurse navigators alongside bedside nurses to help manage care coordination as well as the transition of care to aide in the improvement of effective, safe and efficient healthcare provided to all patients.