By Melinda Young
A stroke nurse navigator team can prevent 30-day readmissions in stroke patients treated with thrombolysis, investigators found.1
A health system’s 30-day readmission rate was 13.6% before it began to use a stroke nurse navigator. The rate declined to 6.9%. Patients with the stroke nurse implementation were 67.6% less likely to be readmitted within 30 days compared to patients without the navigator.
“We can’t speak for all strokes, but for one stroke population that got tPA [tissue plasminogen activator], that improves outcomes,” says Adalia H. Jun-O’Connell, MD, MBA, lead study author and an adjunct associate professor in the department of neurology at the University of Massachusetts Chan Medical School.
Navigators Provide Education, Assistance
Stroke nurse navigators can improve the patient’s quality of life, knowledge of strokes, and self-efficacy. “Stroke navigators are becoming very important in care transition,” Jun-O’Connell says. “What we’re finding is they do make a difference, and the part that is important is they are acting as patient advocates.”
Stroke patients are particularly vulnerable during the transition between the hospital discharge and ambulatory follow-up. This is where medication errors and gaps in follow-up plans can occur. Unplanned readmissions after a stroke can reach one in five within 30 days and more than half in a year.1-6 A tactic to prevent unplanned readmissions is important to improving patient care. Assigning a nurse navigator to work with patients and walk them through the initial post-discharge steps appears to be important to helping them maintain their health.
“If you had a stroke, getting an appointment, or getting someone to discuss medication management or tell you when to go to the hospital and where to get a test done is important,” Jun-O’Connell says. “There are gaps in tests and [patients] lost to follow-up. Having a nurse navigator [helps] improve outcomes.”
Nurse navigators ensure patients’ medications are reviewed and tests are performed. “They are addressing concerns we may not be addressing in the local setting,” Jun-O’Connell says.
It is challenging for patients to access neurology care in the United States. “Patients wait a long time right now,” Jun-O’Connell says. “As stroke patients are discharged, they have a lot of questions we need an additional way to address.”
Stroke nurse navigators receive a notice when a patient is admitted. Then, on the day of discharge, the inpatient team notifies the nurse navigator to ensure the patient adheres to the follow-up plan.
“The nurse navigator calls the patient within three to seven days of discharge,” Jun-O’Connell explains. “At that point, they review the medications and patient-related questions and make sure follow-up appointments were established. They confirmed the follow-up plans.”
Nurse navigators also make sure patients attend their clinic appointments and undergo the correct tests. “They also assess the functional status and patients’ symptoms concerns,” Jun-O’Connell says. “If the patient doesn’t have an appointment for several months, depending on their symptoms, the nurse navigator might try to get them in to the appointment sooner.”
There is patient demand for dedicated care coordinators to work with stroke patients during the transition period. CMS has started to recognize the importance of this role to support Bundled Payments of Care Improvement initiative.1
“The stroke bundle programs are being done by Medicare to utilize the navigators to improve quality care and for cost improvement, as well,” Jun-O’Connell explains. “It is all about the quality of care — stroke nurse navigators demonstrate quality care, and we have shown that they improve tPA outcome.”
REFERENCES
- Jun-O’Connell AH, Grigoriciuc E, Gulati A, et al. Stroke nurse navigator utilization reduces unplanned 30-day readmission in stroke patients treated with thrombolysis. Front Neurol 2023;14:1205487.
- Nouh AM, McCormick L, Modak J, et al. High mortality among 30-day readmission after stroke: Predictors and etiologies of readmission. Front Neurol 2017;8:632.
- Fehnel CR, Lee Y, Wendell LC, et al. Post-acute care data for predicting readmission after ischemic stroke: A nationwide cohort analysis using the minimum data set. J Am Heart Assoc 2015;4:e002145.
- Kind AJ, Smith MA, Frytak JR, Finch MD. Bouncing back: Patterns and predictors of complicated transitions 30 days after hospitalization for acute ischemic stroke. J Am Geriatr Soc 2007;55:365-73.
- Fonarow GC, Smith EE, Reeves MJ, et al. Hospital-level variation in mortality and rehospitalization for Medicare beneficiaries with acute ischemic stroke. Stroke 2011;42:159-166.
- Vahidy FS, Donnelly JP, McCullough LD, et al. Nationwide estimates of 30-day readmission in patients with ischemic stroke. Stroke 2017;48:1386-1388.
A stroke nurse navigator team can prevent 30-day readmissions in stroke patients treated with thrombolysis, investigators found. A health system’s 30-day readmission rate was 13.6% before it began to use a stroke nurse navigator. The rate declined to 6.9%. Patients with the stroke nurse implementation were 67.6% less likely to be readmitted within 30 days compared to patients without the navigator.
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