Implementation of a Transition-of-Care Model for Adult Ischemic Stroke Survivors

The lasting physical and cognitive deficits associated with the complexities of newly acquired disabilities resulting from an acute ischemic stroke (AIS) may lead to hospital readmissions. The participating healthcare facility on the U.S. West Coast reported a hospital readmission rate for AIS survivors of 24.29% within 30 days of discharge. This doctoral nursing project aimed to determine if implementing the Comprehensive Post-Acute Stroke Services (COMPASS) model would reduce 30-day readmission rates compared to no standardized transition-of-care model in adult AIS survivors over 30 days. Implementing the COMPASS model in this patient population was expected to better educate and support stroke survivors during their transition from acute care to home. A quantitative quasi-experimental design was used to implement the COMPASS model to support postdischarge education in a project sample of 20 adult AIS survivors. A two- proportion z test analysis demonstrated that the elements implemented using the COMPASS model significantly improved AIS 30-day readmission rates. Results from the two-proportion z test were significant based on an alpha value of .05, z = 2.73, p = .006, 95% CI [0.05, 0.33], which demonstrated that the readmission rate was reduced from 24.29% prior to the implementation of the COMPASS model to 5% following implementation. These findings support the COMPASS model as an effective model aiming to address readmission rates among AIS survivors following discharge. It is recommended that by implementing the COMPASS model, providers can improve 30-day readmission rates for AIS survivors. Keywords: adult acute ischemic stroke (AIS) survivors, readmission, COMPASS model, transition-of-care model, ischemic stroke