A Doctor of Nursing Practice-Led Transitions of Care Model for Stroke and Transient Ischemic Attack

Abstract

Background/Objectives: Gaps in care due to the movement of patients between health settings and/or practitioners, known as transitions of care (TOC), may contribute to second stroke or TIA events. The elements that impact TOC in the stroke/TIA population have not been fully elucidated. The purpose of this study is to identify key elements of a Doctor of Nursing Practice-led TOC model that could be used to develop and evaluate a TOC program for the stroke/TIA population. Design: A descriptive study was performed to 1) identify elements that may affect transitions of care using a stroke database and post-discharge phone surveys and 2) based on information from Aim 1, propose a DNP-led TOC model specific to the stroke/TIA. Setting: An urban primary stroke center in the southwest United States. Participants: All patients in the GWTG®-stroke database from May 1 - December 31st, 2012 and patients who consented at discharge from the stroke unit following a stroke or TIA. Measurements: Patient demographics including: length of stay (LOS), age, race, ethnicity, comorbidities, insurance, discharge status, thirty-day readmission rate, and follow up survey. Results: Patient data (n=276) from GWTG®-stroke database was obtained. Average LOS was 7.81 +/- 11.15 days. The majority of patients were greater than age 65 (59%); 53% relied on Medicare support; those age 50-59 (21%) were most likely to be uninsured (47%). Fifty-one percent were discharged directly home, 48% of those were referred to outpatient rehab services. Two-thirds received rehabilitation services during hospitalization. Eight patients experienced a subsequent hospital readmission; two of those had a repeat stroke event. Although patients reported understanding their discharge instructions, their perception of ongoing care was poor. Conclusion: Key elements of a TOC model specific to the stroke and TIA patient population could include: patient surveillance, comprehensive care planning, follow-up, stroke education and point of contact. Advanced practice nurses have been successful in leading such programs, and a DNP-led model providing continuity of care would support the transition of an effective model into clinical practice.