Objective:

To evaluate the effectiveness of a model to improve inpatient-to-outpatient care transitions using a neurology service transitional nurse practitioner (NP).

Background:

Patients with acute neurological disorders frequently have cognitive and physical impairments that create barriers to safe discharges and adherence to post-discharge therapies. Inefficient inpatient-to-outpatient transitions of care can prolong hospital length of stay (LOS) and increase 30-day day readmissions.

Design/Methods:

Outcomes were measured over a 6-year period from May 2016 to May 2024. The NP provided continuity of care with 4 touchpoints: 1) participated in daily discharge round;, 2) evaluated each patient at least once during their hospital stay; 3) contacted each patient within 48h of discharge for medication reconciliation and symptom management; and 4) in-person or telemedicine clinic within 7-14-days post-discharge based on complexity and LACE score. The NP was the point provider until seen by outpatient neurologist. The NP coordinated with the inpatient and outpatient neurologist during the transitional period to ensure care coordination.

Results:

Comparing the pre-intervention period May 2016-May 2017 to the post intervention period May 2017 to May 2024, LOS was reduced from 1.93 to below 1.0. The 30-day post-discharge readmission rate improved from 23.7% to 3.1 %, with SPC Y-chart showing 30- day readmission occurring pre-intervention every 10 days to post intervention every 404 days The G-chart showed stable improvement for individual patients. Press Ganey patient satisfaction improved, demonstrating 98-99% across discharge and transitional survey questions.

Conclusions:

A neurologic NP transition of care model is an efficient discharge process for the stroke, general neurology, and epilepsy monitoring inpatient services. The transitional NP model decreased LOS and 30-day readmissions, while improving patient satisfaction. This model should be explored across multiple inpatient service lines.