Abstract DP215: From Hospital to Home: A Stroke Discharge Model Focused on Caregiver Readiness and Support.

Background: Stroke survivors often face challenges with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and functional mobility in their home and community settings that are not always apparent in the closed environment of the acute care hospital. By ensuring that both the patient and the designated caregiver are aware of the current functional limitations and level of support that is needed to be successful in the home and community, patients returning home after a stroke are more likely to succeed and reach their maximum functional potential. Purpose: The purpose of this project was to create a standard of work where a stroke patient’s caregiver is identified, assessed for readiness, and trained via hands-on functional training prior to discharging to home from the acute care hospital. Methods: An algorithm was developed that outlined the flow of the homegoing stroke patient within the existing discharge pathway, but with the inclusion of an interview of the caregiver by Care Management and hands-on training by Rehab Services (pic 1). A standard set of questions was developed by Care Management to assess the caregiver’s readiness and willingness to support the patient at home (pic 2). Rehab services included specific documentation that addressed the functional training that was needed and if the caregiver completed the training or if it was on-going. Informaticists developed a report to track compliance with the standard work that is shared at monthly process improvement team meetings. Results: From January 2024 through June of 2025, a total of 2,091 stroke patients have been discharged home from the hospital system. The number of caregiver assessments that have been completed by Care Management is 1,069 (51.1%) and the number of caregivers that have engaged in hands-on functional training by Rehab Services is 1,430 (68.4%). Conclusions: In conclusion, the discharge standard work that engages the caregivers of home-going stroke patients has allowed for a comprehensive approach to re-integration into the home and community settings for our patients. Next steps are to continue to educate nursing staff, Care Management and Rehab Services on this standard work to improve compliance with assessments and training. Stroke program leaders are working to collect data on readmission rates for this patient subgroup to continue to validate the efficacy of the assessment and training for those that complete this program.