Abstract WP098: Tackling Post Stroke Transitions: Leveraging Electronic Medical Records (EMR) and Interprofessional Teams

Background: Advancements in stroke care has enabled earlier hospital discharge. Both patients and caregivers express concerns about their ability to manage post-stroke care. There is limited evidence on supportive strategies, highlighting the need to improve care transitions. Purpose: This initiative aimed to reimagine the stroke care pathway by shifting from time-based interventions to a comprehensive episode-of-care model. Methods: Over a 48-month period, an interprofessional team collaborated to design, test, and implement an ideal patient experience across the stroke continuum. Components included redesign of educational materials, development of new workflows, strategic daily huddles, enhanced EMR tools, and integration of a Stroke Nurse Navigator. From August 2023 to June 2025, the project was rolled out in phases across 6 stroke centers and 5 rehabilitation facilities (figure 1). Reporting tracked specific metrics from initial stroke admission through community reintegration. Tactics included role restructuring,customized educational content, interviews with patients, caregivers, and staff. A flexible, multidisciplinary team was essential to ensure smooth transitions across care settings. Results: Figure 2 shows active patients. To date, 27 projects have been launched to enhance the patient/caregiver experience. Key outcomes include a 4% year-over-year increase in referrals to aligned inpatient rehab, home health, and outpatient therapy, reduction in 30-day hospital readmission rates, and increased neurology follow-up appointments at discharge. Lessons learned emphasize the value of listening to staff and patient feedback, maintaining momentum through daily staff check-ins, and adapting strategies to sustain improvements. Unexpected findings included early discharges from observation and emergency departments, missed referrals at discharge, provider engagement, and gaps in education and services contributing to unplanned emergency room visits. Conclusion: Stroke recovery is a complex journey that can overwhelm patients, caregivers, and healthcare providers. Integrated health systems have a unique opportunity to build infrastructure that supports recovery across all care settings. Sustained improvement requires continuous effort to address evolving needs and ensure seamless transitions. Stroke care pathways must evolve and use technology to meet the long-term needs of survivors. Early results suggest that episode-based care models can lead to improved outcomes.