Improving Coordination and Transitions of Care in Stroke Patients

Improving Coordination and Transitions of Care for Stroke Patients With an Attending Nurse: a Comparative Effectiveness Single Center Study Comparing Models of Nursing Care

This study will examine if the attending nurse model will enhance critical patient-centered elements of care that will in turn improve patient education and shared decision-making, medication adherence, stroke-related health literacy, and reduce early readmissions to ultimately yield improved patient quality of life. Our primary objective is to determine whether the attending nurse model of care improves stroke patients' health at 7 days, 30 days, and 90 days after hospital discharge as assessed through questionnaires.

Inclusion Criteria:

• > 18 years of age
• Admission to the Hospital of the University of Pennsylvania Vascular Neurology service
• Incident or recurrent:
• Ischemic stroke: focal neurological deficit of likely ischemic vascular origin
• Intracerebral hemorrhage: blood seen on initial head CT
• Transient Ischemic attack: focal neurological deficit of likely ischemic vascular origin that has clinically resolved

Exclusion Criteria:

• Pregnancy
• Comfort or hospice care
• Severe dementia prior to stroke
• Non-communicative and have no family/social support