A Stroke Transition of Care Intervention with Stroke Nurse Navigators and Early Stroke Clinic Follow-up Reduces Readmissions for Stroke at 12 Months

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Kelly Matmati
Nabil Matmati
Susan Madison
Brian Bixler
Kelsey Vogler
Mary Dombovy
Chris Burke



One in four strokes occur in stroke victims, with hospital readmissions contributing to high-cost care.  Transition of care programs have been successful in reducing hospital readmissions in other diseases, but the data on such programs for stroke are mixed.  A transition of care program was implemented with the goal of reducing recurrent strokes and hospital readmissions.


We implemented a transition of care program using nurse navigators and early outpatient follow-up with a vascular neurologist.  Data were obtained on: Rate of recurrent stroke admissions within one-year, all-cause readmission within one-year, all-cause readmission within 30 days, initial follow-up scheduled within 7-10 days, compliance with follow up, and compliance rates with provision of two-day post-hospital discharge phone calls. 


An improvement was seen in process measures reflecting adherence to the intervention across all 3 years.  The rate of readmission for stroke at 12 months was 8.5%, 9.0%, 6.6%, and 4.2% for year 0, 1, 2, and 3, respectively, representing a 50% reduction from baseline year 0.  All-cause readmission remained unchanged, at 38.9%, 42.6%, 36.6%, and 37.4% for year 0, 1, 2, and 3 respectively. 


Our nurse navigator led stroke transition intervention was associated with significant reduction in readmissions for stroke but did not impact all cause readmission at one year or 30 days.  Our focus on Centers for Medicare/Medicaid intervention compliance has produced a sustainable program capable of now expanding to support other important patient needs.  

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