Abstract TP152: Impact of a Stroke Transition-of-Care Clinic on 30-Day Readmission Rates

Introduction: Effective care transition for ischemic or hemorrhagic stroke patients post-hospital discharge is critical. Ensuring a follow-up neurology appointment within two weeks is vital to managing stroke risk factors like hypertension, diabetes, and atrial fibrillation. Early follow-up helps adjust treatment plans, reducing stroke recurrence. This period also allows for additional patient education, addressing queries, reinforcing lifestyle modifications, medication adherence, and recognizing warning signs. This support empowers patients in their recovery and long-term health. Objective: This study, conducted at a comprehensive stroke center, evaluated the impact of a newly established transition-of-care clinic on stroke patients' hospital readmission rates. We compared 30-day readmission rates before and after the clinic's implementation. Before the clinic, patients typically followed up with their primary care provider and saw a neurologist with delays. Since the clinic's inception, all stroke patients have been seen within two weeks of discharge. The clinic aims to support patients, manage stroke risk factors, and ensure a seamless transition to primary or outpatient neurology care. We assessed the clinic's effectiveness in improving outcomes and reducing stroke-related readmissions by analyzing readmission rates. Methods: We utilized our internal data monitoring system to analyze the 30-day readmission rates of all ischemic and hemorrhagic stroke patients during two distinct periods. The first period, from July 2022 through June 2023, represents the timeframe before the opening of the transition-of-care clinic. The second period, from July 2023 through May 2024, corresponds to the timeframe following the clinic's establishment. This comparison allowed us to assess the clinic's impact on reducing hospital readmissions. Results: From July 2022 to June 2023, 1,181 stroke patients were discharged with a 30-day readmission rate of 6.1%. Post-clinic, 1,039 stroke patients were discharged between July 2023 and May 2024, with a 30-day readmission rate of 4.2%. This marks a 31% reduction in readmissions since the clinic's establishment. Summary: The stroke transition-of-care clinic has significantly reduced 30-day readmission rates, improving patient outcomes. Ongoing data collection will evaluate the clinic's long-term effects, particularly on secondary stroke prevention.