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Abstract Details

Short-term Post Discharge Care, Long-term Benefits - A Transitional Model of Care
General Neurology
S51 - General Neurology: Models of Clinical Care and Disease (1:24 PM-1:36 PM)
003
Patients with acute neurological disorders frequently have new cognitive and physical impairments that are barriers to early safe discharge and adherence to post-discharge therapies.  Inefficient handoff and inpatient-to-outpatient care coordination can prolong hospital length of stay (LOS) and increase post-discharge emergency department (ED) visits and readmissions. 
To evaluate the effectiveness of a transitional nurse practitioner model in improving inpatient-to-outpatient care transition among neurology patients.  

A new neurologic nurse practitioner (NP) transition of care service was implemented for the stroke and general neurology inpatient services at UCLA, and outcomes assessed during the 2.5 year period from May 2017 to October 2019. The NP provided continuity of care with 4 touchpoints: 1) participated in daily discharge rounds, 2) evaluated patient personally at least once during hospital stay, 3) contacted patient by phone within 48 hours of discharge for medication reconciliation and symptom management, and 4) saw patient in- person or telemedicine clinic within 14 day post-discharge. The NP coordinated with both the inpatient and outpatient neurologists during the transitional period until long-term care was resumed by the outpatient neurologist.

Introducing the transitional NP model was associated with: reduced post-hospital discharge ED visits [49.2 to 37/mo, relative reduction (RR) 34%] and reduced unplanned readmissions [12.9 to 0.9/mo, RR 93% for stroke, and 6.6 to 3.97/mo, RR 40% for general].  Both services experienced a LOS observed/expected below 1. Patient satisfaction reported (Press Ganey) was 98-99% across discharge and transitional planning items.

The transitional NP model for stroke and general neurology improves LOS, reduces emergency room and hospital readmissions, and enhances patient satisfaction.  This model should be explored across multiple specialty service lines in the future.

Authors/Disclosures
Melissa Reider-Demer, DNP, MN, CNP (UCLA Medical Group)
PRESENTER
Dr. Reider-Demer has nothing to disclose.
Jeffrey L. Saver, MD, FAAN (UCLA Health) Dr. Saver has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Medtronic. Dr. Saver has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Stryker. Dr. Saver has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Cerenovus. Dr. Saver has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Boehringer Ingelheim (prevention only). Dr. Saver has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Medical Association. Dr. Saver has received stock or an ownership interest from Rapid Medical.
Inna Keselman, MD, PhD (UCLA) Dr. Keselman has nothing to disclose.