Abstract DP145: Mobile Integrated Health Partnership Improves Post-Discharge Outcomes

Introduction: In Wisconsin (WI), approximately 75% of those with a principal diagnosis of stroke have pre-existing hypertension. Managing hypertension after discharge is key in preventing a secondary stroke. Furthermore, transition of care to home for many stroke patients is suboptimal. Evidence indicates that 30-day all-cause readmission of stroke patients is 17.4% nationally. From 2023 to 2025, the WI partnered with a Mobile Integrated Health (MIH) team at an emergency medical service (EMS) agency and a hospital to improve follow-up care and coordination after an acute stroke hospitalization. Methods: Workflows, eligibility criteria, and data tracking tools were established. Patients discharged home with a final diagnosis of hemorrhagic or ischemic stroke were eligible for an MIH visit . The MIH team engaged the patient within 30-days post-discharge. After a completed visit, the MIH team sent a summary form via secure email to the referring hospital. This form mirrored post-discharge data metrics in Get With The Guidelines® (GWTG). Upon receiving the summary form, the hospital entered the data into the local GWTG database, which was then analyzed using descriptive statistics. Results: In total, 72 stroke patients received a home visit from the MIH team with data entry in GWTG. The MIH project data was compared to 12 WI hospitals entering into the GWTG Post-Discharge tab during the same timeframe. Comparison hospitals may or may not have MIH activity. Results showed: MIH hospital outperforms in 30-day readmission, blood pressure (BP) monitoring by patient, and appointment scheduled prior to discharge. MIH hospital underperforms in falls reported by patient , ED visits, and tobacco use. In addition, there were improvements from year 1 to 2 in appointment scheduled prior to discharge and BP reported . Conclusions: MIH programs can enhance post-discharge outcomes by reinforcing education, ensuring follow-up care, and identifying gaps in resource utilization. Many factors influenced the data. First, the population in the MIH program was from an urban environment with more proximate post-discharge resources. All WI hospitals do not share this setting. Second, MIH data collection involves an in-person home visit. Data collection from comparison hospitals mostly occurred via a phone call or chart review. The MIH method facilitates an environment where more truthful disclosures may result. MIH partnerships should be explored to optimize transitions of care.