Abstract WP329: A Bridge from Hospital to Home: Connecting Minnesota Stroke Survivors to Individualized Support and Community Resources Post Stroke

Introduction: There are over 100,000 stroke survivors living in Minnesota (MN) and recovery after stroke can vary greatly from person to person. Addressing the post-stroke needs of stroke survivors is an essential component of the stroke continuum of care. Furthermore, MN Stroke Registry data illustrates that 22.6% of reported stroke cases in 2024 had a documented history of prior stroke. In response, the MN Department of Health (MDH) partners with the MN Stroke Association’s longstanding Resource Facilitation (RF) program to improve stroke survivors' recovery and quality of life through timely and consistent post-discharge outreach – with a new initiative on introducing secondary stroke prevention strategies within this priority population. Methods: RF is a free, statewide, phone-based support service that originates from evidence-based research and is available as part of the rehabilitation process post-stroke. MDH collaborates with statewide acute care hospitals and rehabilitation programs on developing standardized RF enrollment processes. Enrollees receive two years of individualized support, connection to community resources, and secondary stroke prevention education including hypertension awareness. A key intervention, and strength, of the RF program is in the interview process. RF staff are trained to utilize person-centered, strength-based, trauma informed care models during calls to assess and address individual barriers to better health and quality of life. Cultural considerations are also integrated into RF with support calls and resources provided in Hmong, Spanish and English. Results: From January 2023 to December 2024, the RF program demonstrated measurable success. RF call data illustrates that 1,790 active participants with a history of stroke received a total of 20,360 support calls covering a wide range of needs. Common referrals include connection to support groups, housing, transportation and stroke prevention education. Satisfaction survey respondents agreed that various program offerings are useful, supportive, and helpful with 71% asking for continued support calls after year 2. Conclusions: RF program data illustrates that a community-based program providing consistent support can have a meaningful impact on an individual’s recovery post stroke. In conclusion, it is recommended that the RF program remain an essential service available to stroke survivors as part of their rehabilitation journey and prevention of secondary stroke.