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.