Transitional Stroke Clinic Lowers 30-Day Readmissions.

Abstract

Wake Forest Baptist Medical Center’s transitional stroke clinic, developed to provide standardized care for stroke patients discharged to home, resulted in a 48% lower risk of 30-day readmissions among patients who made just one visit to the clinic. The clinic is run by nurse practitioners who see patients within 14 days of discharge and assess them for medical, cognitive, and psychosocial needs, conduct medication reconciliation, and screen for caregiver burnout. Patients attend the clinic in addition to going to their regular follow-up visits with the neurology clinic, their primary care providers, and therapy sessions. The model also includes follow-up phone calls by an RN within two days of discharge to ensure patients have filled their prescriptions and know how to take their medication, if any equipment has arrived, and to continue the education started in the hospital.