Abstract WP312: Navigating the Road to Recovery: Guiding Patients Beyond Discharge: A 90-Day Post-Discharge Model

Introduction: Effective care coordination following hospital discharge is crucial for reducing readmissions and enhancing patient outcomes. This quality improvement initiative evaluates the impact of a Nurse Navigator follow-up model, which incorporates 30-day and 90-day post-discharge visits, along with multiple patient touchpoints, over 90 day period spanning two years. Nurse Navigators conducted structured phone calls and coordinated care plans. They maintained ongoing communication with rehabilitation facilities, long-term acute care hospitals (LTACHs), long-term care facilities, as well as Primary Care Providers (PCPs) to ensure seamless transitions and proactive management of patient needs. Methods: Patients received a structured, multi-touchpoint follow-up model led by a Nurse Navigator. An initial phone call was completed within 72 hours of hospital discharge to assess immediate needs. Subsequent phone check-ins were scheduled at 7 and 21 days for all stroke and TIA patients, with an additional 75-day call for those who received Tenecteplase or underwent an endovascular procedure. These calls were tailored to each patient’s risk factors and disposition, focusing on symptom assessment, adherence to treatment plans, and addressing any emerging concerns. In-person or telehealth visits were scheduled at 30 and 90 days post-discharge for patients treated with Tenecteplase or who underwent an endovascular procedure, providing an opportunity for more intensive post-acute care. Results: At 21 days post-stroke, 70% of patients in the intervention group were successfully reached by the nurse navigator. Among all stroke patients, 94% attended their scheduled 30-day clinic follow-up visit. Following the message sent to primary care providers, 94% of patients had a documented visit with their HMC PCP before the 30-day follow-up. Conclusion: This Nurse Navigator model demonstrated strong patient engagement and effective care coordination during the critical 90-day post-discharge period. High rates of follow-up visit attendance and successful communication with primary care providers highlight the value of structured, multi-touchpoint follow-up. By bridging care transitions and proactively addressing patient needs, the program supports improved recovery trajectories and may contribute to reducing readmissions in post-stroke populations. Future expansion of this model may further enhance continuity of care and long-term patient outcomes.