Abstract 207: Beyond the Hospital: Evaluating the Durability of Outcomes for Stroke Survivors Receiving Principal Illness Navigation Services

Introduction/Purpose Post‐acute navigation services for stroke survivors have started to emerge over the last few years, spurred on by high readmission rates and subpar quality of life in the months after stroke discharge. While there is limited but promising evidence related to the outcomes of these navigation services post‐stroke, there have been few studies that have reviewed the durability of outcomes such as longitudinal readmission rates, quality of life metrics or functional status. This study aims to assess the 6‐months and 1‐year post‐discharge outcomes for stroke patients receiving post‐acute of Principal Illness Navigation (PIN) services. Measures will include inpatient readmission rates, quality of life via the PROMIS Global 10 and the modified Rankin Scale. Materials/Methods This is a mixed methods design including the retrospective analysis of readmissions data via historical HIE and ADT feeds along with the assessment of QoL and mRS based on patient report (PROMIS Global and 1 question mRS, respectively). In addition, patient and care partner surveys were conducted at 6‐months and 1‐year to assess ongoing recovery challenges as well as the longitudinal impacts of participation in PIN services after hospital discharge following stroke. Results Our abstract will review inpatient readmission rates for patients who reached at least 6 months post‐discharge, and those who reached at least 12 months post‐discharge. We will compare these results to published benchmarks, reporting 12‐month readmission rates ranging from 30% to nearly 50%. We will also report on patient self‐reported health challenges, SDOH concerns, and ability to live independently at 6 and 12 months post‐stroke. Conclusion The findings from this study will highlight the potential durability and long‐term benefits of Principal Illness Navigation (PIN) services for stroke survivors, particularly in reducing readmission rates compared to published data. Stroke patients historically experience very high and recurrent readmissions, and persistent challenges related to ambulation, fatigue, mental health, and socioeconomic stressors. Our preliminary results suggest that PIN improves key outcomes and that there is still a need for ongoing, comprehensive support beyond the first year of recovery. Addressing these long‐term needs, particularly mental health, will be critical to further enhancing stroke survivors’ quality of life and functional independence.