Abstract NS21: Identification of Opportunities to Improve Stroke Patients Transitions of Care Among a Subset of Hospitals in the Michigan Coverdell Stroke Registry

Background: Stroke patients are at high risk for complications and hospital readmissions, ranging from 6.5% to 24.3% 30 days post-discharge. Evidence-based interventions for prevention of stroke readmissions are not clearly defined and surveillance data for transitions of care (TOC) are lacking. The Michigan Coverdell Stroke Registry is conducting surveillance to understand the current processes in order to assist hospitals to develop, implement and evaluate strategies to improve stroke TOC. Methods: Data were collected from 395 cases from three hospitals from October 2013 to March 2014. Stroke nurses at each hospital collected data on selected transition of care elements via a combination of follow-up phone calls and chart review at different time intervals within 30 days of hospital discharge. Patients who died in-hospital or were discharged to a skilled nursing facility were excluded. Results: Of the 395 cases, 357 (90.3%) of patients had a recorded history of high blood pressure. A total of 19.0% (N=6...