Abstract NS12: Stroke Mobile: Implementing A Novel Family Centered, Home-Based Post-Discharge System of Care

Total annual costs of stroke-related care and loss of post-stroke productivity are projected to reach $241 billion by 2030, an increase of 129% since 2010. Although comprehensive stroke care programs have contributed to reductions in recurrent strokes, readmissions, and stroke-related complications, this population is vulnerable to non-adherence to the plan of care during the first year. Innovative in-home programs that coordinate team-based care hold promise for positively impacting this public health threat through greater emphasis on effective prevention, adherence, and optimizing outcomes. Purpose: The purpose of this project was to evaluate the implementation of a home-based post-discharge stroke mobile program to existing comprehensive stroke care. Methods: An inter-professional team of stroke specialists (physicians, advanced practice nurses, registered nurses), and administrative and financial specialists collaborated to develop an innovative, family-centered, home-based approach to post-discharge stroke care. The team identified project goals, assessment tools, and 12-month post-discharge outcome metrics. Telemedicine technology enabled a direct link between the mobile team, patient, and an APN or Neurologist to reduce office/emergency visits, and lower costs. Results: Training of the home-based team included stroke specific education, along with training in communication skills and family-based interventions. Home visits were structured to occur once per month for 1 year post stroke. Each visit was designed to impact specific elements related to enhancing physical recovery, preventing readmissions and stroke recurrence, improving medication compliance, risk factor management, and caregiver support. Fifteen of 24 (63%) received all scheduled visits, and all planned visits did not occur in 9/24 (37%) due to patient’s schedule. Only 2/24 (8%) were readmitted for stroke recurrence. Lessons learned include need to validate contact information before discharge; develop a brochure that targets program enrollment; and explore options to visit in other settings. Conclusion: A family centered, home-based, post-discharge system of care is a viable solution to addressing the complex needs of the stroke patient.