Qing Hao, MD, PhD

After discharge from hospital, strokes survivors usually are faced with physical and cognitive impairments, complex medication regimen, new diagnosis of other medical illness and need of social support which all significantly affect stroke recovery and readmissions due to stroke related complications or other medical conditions. The experience from non-stroke patients that addressed the cumulative complexity (patients’ demands and capacity) have demonstrated effective interventions for reducing 30-day readmissions, however, the transitional care models for stroke patients have not been well established. Condon and colleagues developed a model of Transitional Stroke Clinic (TSC) led by nurse practitioner(NP) and investigated its role in reducing readmissions by conducting an observational quality improvement study in a single academic, tertiary referral center.

Two phases of transitional care model were implemented from 10/2012 to 09/2015: 

Over 3 years, among 1421 stroke or TIA patient who were discharged home, 510 patient were enrolled into the transitional care model with a mean age of 65 and median NIHSS of 2. A lower TSC show rate was observed in patients readmitted within 30 days (60.8% vs 76.3% not readmitted; p=0.021); a similar trend was noticed in those readmitted within 90 days (67.5% vs 76.4%; p=0.088).
Multivariate analysis showed the TSC visits independently reduced the 30-day readmission by 48% (OR 0.518, 95% CI 0.272, 0.986; p=0.045), and the reduction was not significant for 90-day readmission. Prior stroke and multiple chronic conditions were associated with both 30-day and 90-day readmission.  Other factors that significantly affected 90-day readmission were prior hospitalization, and male gender.
Interestingly, compared with phase I, the phase II protocol made more follow-up phone calls earlier and were able to see all patient in TSC earlier using a structured clinic visit template (although the details of structured vs not structured were not specified), the rate of TSC visit and readmissions in 30 day and 90 day did not differ significantly in two phases.  This is probably because the readmission mainly occurred in high-risks patients, by focusing on this group of population, phase I protocol was able to effectively reduce the readmission rate. In addition, both phases followed the concept of cumulative complexity and spent significant effort on education, coordinating care with referral to therapy and community services, addressing social needs and handing off the care to the primary care which are also important interventions that enhanced patient care.  The phase I model that requires less time and resources may be preferred in future practices, but further investigations are needed. 
With a few limitations (e.g., not covering the patients who were discharged to rehab or skilled nursing facilities with higher NIHSS and who may be at higher risks of readmission, possibility of underestimation of readmission rate), this study showed promising result that early evaluation in NP-led structured transitional clinic was able to reduce readmission at 30 day by about 50% in stroke patients who were discharged home.  We are very glad that a pragmatic clinical trial based on these results is being implemented in North Carolina and we look forward to the standardized, effective and practical transitional care models for stroke survivors.