Stroke and Transient Ischemic Attack Care Transitions Clinic: Providing Timely, Evidence-Based Care
Shivani Daryani1, Evan Kolesnick1, Halina White1, Saad Mir1, Dana Leifer1, Ava Liberman1, Alan Segal1, Matthew Fink1, Hooman Kamel1, Babak Navi1, Neal Parikh1
1Weill Cornell Medical College
Objective:
To demonstrate the impact the of a Care Transitions Clinic (CTC) for patients with Stroke/TIA.
Background:
Patients seen in the ER and hospital for stroke/TIA have variable ambulatory follow-up. We implemented a protocol for timely, evidence-based ambulatory follow-up care.
Design/Methods:
We conducted a retrospective review of patients seen in the CTC from November 2021-August 2022. The clinic serves patients with stroke/TIA within 3 weeks of hospital/ER discharge from our main campus and a community affiliate. Persons with established neurologists and those discharged to skilled nursing, long term acute care, and hospice services are excluded. In response to inpatient team requests for CTC appointments, designated clinic slots are released to discharge paperwork. A stroke PA sees the patient using a visit template and staffs the visit with a supervising stroke neurologist. The template focuses on etiologic work-up, secondary prevention optimization, lifestyle modification, education, incidental findings (e.g., intracranial aneurysm, echocardiogram abnormalities, thyroid and pulmonary nodules), and care coordination. Patients are provided follow-up with the supervising stroke neurologist to finalize etiologic diagnoses and secondary prevention plans.
Results:
Among 85 patients (59 from main campus, 26 from community affiliate) seen in CTC, mean age was 68 years and 39% were women. Diagnoses were: 61% ischemic stroke, 6% retinal event, 9% hemorrhagic stroke, and 24% TIA. The median time from discharge to CTC was 15 days (IQR, 11-23). For patients with ischemic events, >1 diagnostic test to ascertain etiology was ordered in 58% of visits, and appropriate antithrombotic and statin treatment was confirmed in 95%. Blood pressure was > 130/80 in 44%; these patients were offered 7-day blood pressure logs and dedicated hypertension management follow-up. Incidental findings were frequently addressed (total 49; >1 finding in 38% of visits).
Conclusions:
A team-based approach achieved its goal of connecting patients with stroke/TIA to outpatient care in a timely, standardized manner.