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The Advanced Practice Nurse Will See You Now

Impact of a Transitional Care Clinic on Hospital Readmissions in Stroke Survivors

McClain, Jesse V. IV DNP, APRN, ACNS-BC, CCRN, MSCN, SCRN; Chance, Elisha A. BSAS, CCRC

Author Information
Journal of Nursing Care Quality: April/June 2020 - Volume 35 - Issue 2 - p 147-152
doi: 10.1097/NCQ.0000000000000414


Stroke and transient ischemic attacks (TIA) are among the top 5 causes of death and disability in the United States.1,2 Preventable rehospitalizations are significant factors in cost and hospital resource use, costing billions of dollars annually.3 Between 3% and 24% of patients with stroke/TIA are rehospitalized within 30 day of their first stroke.4–12 Up to 30% of stroke survivors are rehospitalized within 90 days,5,8 and about 60% experience a hospitalization within a year of their first stroke.9,12 Each subsequent hospitalization, regardless of diagnosis, increases the risk of disability and all-cause mortality in stroke survivors.3,13

Stroke survivors commonly have chronic illnesses, significant disability, and ongoing care needs at the time of hospital discharge.3 The most common diagnoses for subsequent hospital encounters after a stroke include recurrent stroke, infections, chronic cardiac conditions, gait dysfunction-related falls, and dysphagia.4–6,9,12,14–16 However, the underlying reasons are most often related to undertreated problems at discharge, patient and caregiver lack of understanding, poor posthospital care coordination, and socioeconomic disparities.3,6,8–11,15–18 Qualitative investigations into readmitted patients with stroke/TIA reveal there is clear patient and caregiver misunderstanding about follow-up, course of recovery, and points of contact despite well-documented education and written acknowledgment in the medical records.6,11 The Medicare Payment Advisory Committee (MedPAC) estimates that 12% of all 30-day readmissions are avoidable.19,20 In 2010, the US Congress enacted the Hospital Readmission Reduction Program (HRRP), financially penalizing institutions with excess readmissions.19,20 Despite the knowledge, incentive, and efforts to reduce readmissions, there remains no consensus on evidence-based posthospital stroke care in the United States.15,17

Reported strategies to prevent unnecessary hospital readmissions include discharge process improvement, implementing hospital-to-home transition clinics, education, emotional support, physical and occupational therapy (PT/OT), medication reconciliation, and referral to community-based services.5,8,16–18,21,22 Two nurse-led interventions report reduced 30-day hospital readmissions for stroke survivors discharged home.5,8 In Poston et al's study,8 there was an improvement when registered nurse (RN) navigators scheduled patients' follow-up appointments and transmitted hospital discharge summaries to primary care physicians (PCPs). Condon et al5 reported a significant reduction in 30-day readmissions after implementing an RN-initiated, structured, follow-up call and in-person advanced practice registered nurse (APRN) evaluation at their transitional care stroke clinic. Their model is the basis of the ongoing Comprehensive Post-Acute Stroke Services (COMPASS) trial, a cluster-randomized pragmatic trial, designed to reduce hospital readmissions and increase functional status in stroke survivors.15

RNs and APRNs are recognized for leading most transitional care models reported in the literature.5,6,8,15,21,23,24 There is consensus that APRN-delivered care is equivalent to, and sometimes better than, physician-delivered care.23–25 The purpose of this article is to describe implementation of an APRN-led transitional care stroke clinic for recently discharged stroke and TIA survivors and compare 30- and 90-day hospital readmission proportions for patients seen and not seen in the stroke clinic.



This institutional review board-approved retrospective, descriptive chart review was conducted at a Joint Commission-certified primary stroke center in northeast Ohio. Prior to stroke clinic implementation, discharge care included a standardized discharge summary produced by the electronic medical record and 1 postdischarge phone call. The discharge summary includes medication reconciliation, home instructions, and follow-up appointments needed and/or scheduled. Historically, stroke/TIA survivors were instructed to follow up with their PCP as soon as possible. Patients without a PCP were encouraged to establish 1 at the site's family health center. An RN made follow-up calls within a week to all recently discharged patients with stroke/TIA. The RN asked patients whether they had adequate understanding and/or questions about their diagnoses, risk factors, signs and symptoms of stroke, medication purposes and side effects, ability to fill prescriptions, and schedule follow-up appointments per the discharge instructions.

The institution's historical data for 2013 revealed that 10% of stroke/TIA survivors had hospital follow-up with a provider. To address this, a transitional care stroke clinic was implemented at the site (in November 2014), in addition to the standard discharge process described earlier, to improve patient transitions from hospital to home. Patients discharged to acute rehabilitation, skilled nursing, or long-term facilities were not targeted for the clinic because their care continues under another provider. An APRN well-established in neurology conceptualized and led the clinic.

At implementation, there was only enough clinical space, staffing, and available provider time to accommodate 6 appointments, or ½ day, per week because the clinic space and basic staffing (reception and medical assistant) was shared with other specialties. The APRN had limited availability because of other commitments to inpatient care, outpatient care, and on-call requirements. Speech and PT/OT therapists were “borrowed” for ½ day from their respective service departments. This time and space barrier made it unfeasible to see every stroke patient discharged home in a timely manner. Staff aimed to have stroke clinic appointments scheduled within 3 weeks of hospital discharge. Appointments were contingent on either a provider-placed referral or a staff RN call to the neurology secretary. Appointments were not prompted by the electronic medical records based on order sets, diagnoses, or the admitting service.

During a stroke clinic appointment, a patient was evaluated by a PT/OT and a speech pathologist, who made therapy recommendations. The APRN performed a physical examination and detailed medication reconciliation. In addition, the APRN provided refills, referrals, and ensured the diagnostic pathway for stroke etiology was completed. Finally, the APRN and research coordinator optimized the comfortable setting of the stroke clinic to start the informed consent process when appropriate. Throughout the visit, the APRN reiterated stroke education, provided counseling and emotional support, referred patients to community resources, and addressed any questions or concerns.


Inclusion criteria were adults 18 years or older, diagnosis of ischemic or hemorrhagic stroke or TIA during the 2015 calendar year, and discharged home. Patients were excluded if they were admitted solely for stroke-mitigating procedures such as carotid endarterectomy. Collected variables included demographics (age, gender, and ethnicity), index event type (stroke or TIA), stroke clinic attendance, days from discharge to clinic appointment, hospital readmission within 30 days and/or 31 to 90 days, days from discharge to readmission, and primary readmission diagnosis. In readmitted patients only, the authors collected information on missed clinic and follow-up appointments with providers. Stroke severity and other hospital-level care characteristics were not collected because multiple investigations using large data sets have concluded that these hospital and patient-level characteristics are not strongly associated with unplanned readmissions.4,7,10,14,16

For the purposes of this analysis, readmissions were defined as an unplanned hospital readmission occurring 0 to 30 days (30-day) and/or 31 to 90 days (90-day) after hospital discharge. Patients seen and discharged from the emergency department, or with scheduled, elective admissions, were not considered rehospitalized. Secondary to wide coding variation, primary readmission diagnoses were grouped as such: stroke/TIA or stroke-like symptoms, bleeding, cardiac, infection, falls, and other. Data were entered into Microsoft Excel 2013 (Microsoft, Redmond, Washington) and imported into SPSS 25.0 (IBM, Armonk, New York) for analysis. Pearson χ2, Fisher exact test, and analysis of variance (ANOVA) comparisons were performed where appropriate. Statistical analyses are displayed throughout the text, table, and supplemental digital content as such: Pearson χ2(degrees of freedom, P value); Fisher exact test (unadjusted odds ratio, P value); and ANOVA (F value, P value).


In the first full calendar year after the stroke clinic's opening, 899 patients with stroke/TIA were hospitalized and 403 met criteria for inclusion. There were 249 (61.8%) ischemic and hemorrhagic strokes and 154 (38.2%) TIAs. Approximately 17% (68/403) were evaluated in the stroke clinic. Mean time to clinic appointment was 17.3 days (standard deviation [SD] = 9.4, range 1-48).

Overall, males comprised more than half of the sample (52.1%), and the mean age was 67.3 years (SD = 14.1). Group characteristics are displayed in the Table. About 20% of stroke survivors had a readmission at any time between 0 and 90 days (79/403). When grouped by timing, proportions were identical for 30- and 90-day readmissions (11.4% vs 11.4%). Less than 5% of the sample had both 30- and 90-day readmissions (13/403). Overall mean time to readmission was 31.2 days (SD = 27.2, range 1-90). For patients with 30-day readmissions, average days to readmission were 11.6 (SD = 8.7, range 1-28). Those with 90-day readmissions averaged 58.6 days (SD = 18.92, range 32-90) to readmission.

Clinic and nonclinic patients had similar demographics (Table). Nonclinic patients had significantly higher overall and 30-day readmission proportions than clinic patients (Table). When 90-day readmissions were compared, nonclinic patients were numerically more likely to be readmitted compared with stroke clinic patients (Table). Likewise, nonclinic patients were numerically more likely than clinic patients to be readmitted during both time frames (3.9% vs 0%, respectively, odds ratio = 0.961, P = .138). When patients were grouped by index event type, stroke survivors were more likely to be seen in the clinic than TIA survivors (75% vs 25%, respectively, χ2(1)= 6.049, P = .014). Readmission proportions, days to clinic, days to readmission, and readmission diagnoses were similar between stroke and TIA survivors.

Sample Characteristics and Comparisons

The most common readmission reasons were stroke/TIA or stroke-like symptoms (31.6%), cardiac (24.1%), other (13.9%), and infection (11.4%). When grouped by timing, patients with 30-day readmissions were likely to be readmitted for stroke-like symptoms and those with 90-day readmissions were likely to be readmitted for cardiac-related conditions (Supplemental Digital Content, Table, available at: In patients who had admissions during both time periods, no clear diagnosis trend was identified (Supplemental Digital Content, Table, available at: Readmission diagnoses were similar between clinic and nonclinic patients (χ2(5) = 7.532, P = .184).

For the 79 patients who experienced a readmission, 33 of 34 who answered the RN follow-up call stated they scheduled follow-up appointments. When 6 missed stroke clinic appointments were grouped by readmission timing, there were equal proportions in each time frame: 2 in the 30-day readmission group, 2 in the 90-day readmission group, and 2 in the group that experienced both 30- and 90-day readmissions. Out of the 6 missed appointments, 4 had follow-up appointments per their discharge instructions.


In this article we describe implementation of an APRN-led transitional care clinic and compare hospital readmissions between clinic patients and nonclinic patients during its first full year after implementation. Less than a quarter of eligible patients (17%) were evaluated in the stroke clinic. As detailed in the Methods section, barriers contributing to this included available clinical space, staffing, pathway to scheduling, and APRN availability. Notably, significantly more stroke survivors were seen in the clinic than TIA survivors. This finding points toward appropriate allocation of limited appointments. Despite the implementation obstacles, the reduced 30- and 90-day readmission proportion for clinic patients appears promising.

Overall readmission proportions in the current investigation are in accordance with published readmission proportions.4–12 Clinic patients had a significant reduction in 30-day readmissions to 1.5%. Readmissions at 31 to 90 days were numerically reduced to 4.4%. The 90-day readmission comparisons might reach statistical significance in a larger sample. The findings are similar to the results of Condon et al's study,5 which concluded that their APRN-led transitional stroke clinic was associated with reduced hospital readmissions at 30 days but not at 90 days.

The current authors also report a unique proportion: stroke/TIA survivors readmitted within both 30 and 90 days postdischarge. This proportion (3.2%) may signal toward an especially high-risk group of stroke survivors. Other investigations conclude that hospital readmissions are significantly associated with comorbidities and previous hospitalizations.5,9,12–13 This cohort with multiple readmissions in 90 days could be a focus for future transitional care research.

Average time to clinic appointment was 17 days, which is identical to the discharge-to-clinic time reported in Condon et al's study.5 Unfortunately, average time to 30-day readmission was shorter, roughly 12 days. Haynes et al6 also reported an average of 12 days to readmission. At first glance, it is easy to presume that the clinic was only successful at reducing 30-day readmission rates because stroke/TIA survivors were readmitted before their appointments. However, there were only 2 patients in the 30-day readmission group that missed their clinic appointment, and they had documented follow-up appointments with their PCPs. Only 1 of the survivors seen in the clinic experienced a 30-day readmission prior to their clinic appointment, triggered by Holter monitor findings. This rehospitalization would not have been prevented had the patient been evaluated in the clinic at an earlier date. Based on the findings, the stroke clinic team set a benchmark to have patients scheduled within 2 weeks of hospital discharge.

As expected, the most common reasons for any readmission at 0 to 90 days were stroke-like symptoms, cardiac comorbidities, infections, and other. These findings are in line with published stroke recurrence rates, and among the most common readmission reasons reported.4–5,9,12,14–16 In the current sample, 30-day readmissions were significantly associated with stroke-like symptoms. Indeed, up to half of recurrent strokes will occur in the weeks after the index event, even with antiplatelet therapy adherence.14 Readmissions at 90 days were driven by cardiac-related conditions. This was also expected; evidence supports that cardiac comorbidities are significant risk factors for stroke/TIA, associated with readmissions, and associated with mortality risk.2,5,12,13 The overall proportion of patients readmitted for infections and other reasons signals toward the comorbidity influence on unplanned readmissions. Future research could examine whether the addition of a cardiac-specialist on the transitional care team further improves readmission rates.

The APRN-led stroke clinic may influence hospital readmissions for several reasons. Stroke/TIA survivors who receive PT/OT within the first month after discharge are less likely to be readmitted at 31 to 60 days.22 The PT/OT evaluations in the clinic allow patients and caregivers to communicate difficulties they experience readapting to normal activities at home that were not identified during their hospitalization. Speech and language pathology assessments in the clinic are beneficial by the same concept because unidentified swallow and speech problems can emerge after hospital discharge.

The detailed medication reconciliation by the APRN is an important aspect of the clinic visit. Despite well-documented acknowledgment and understanding in the medical record, qualitative investigations report that stroke/TIA survivors and their caregivers are not confident about their medication changes.6,11 In addition, the APRN ensures the diagnostic pathway for stroke etiology is complete and shares not just the results, but the implications with the patient/family. A Canadian transitional stroke clinic study concluded that clinic patients were more likely to have evidence-based diagnostic testing and evidence-based therapy than nonclinic patients.18 Finally, giving an opportunity to take part in a clinical trial provides the stroke/TIA survivor with therapy options that may not otherwise be available.

The stroke clinic is likely successful because it provides for the survivor and caregiver as a whole, which fosters patient-centric care rather than diagnosis-centric care.20 Strategies used in the APRN-led stroke clinic are meant to empower survivors and encourage self-management.


There are several limitations in this investigation. First, the study design was single-site and retrospectively designed. The COMPASS trial results will be pivotal to the future of transitional care practices.15 Second, the sample size was relatively small and only included the first full calendar year after the stroke clinic's implementation. Trending several years of data would increase the sample size and add further meaning to the findings. Erroneous coding is inherent to retrospective design, and some eligible patients may not have been evaluated in this sample because their primary diagnosis was not properly coded.

The authors did not compare APRN-led transitional care to physician-led transitional care or absent posthospital care. This comparison would be futile since APRN-led care has been found to be equivalent or better than physician-led care.23–25 Furthermore, HRRP enactment implies that current posthospital care in the United States, regardless of provider type, is ineffective at preventing hospital readmissions.19,20

The authors did not distinguish hemorrhagic from ischemic stroke patients. The authors did not track missed clinic appointments and phone follow-ups in the nonreadmitted group. This would have informed readmission characteristics. In addition, looking retrospectively, it could not be ascertained whether patients cancelled appointments or were “no-shows.” This information would provide further insight into the findings and advise strategic decision-making for the stroke clinic.

Since the electronic medical record is specific to the hospital system, the authors could not capture readmissions to different hospital systems. This limitation is also cited by other investigators.5,9 In addition, the authors did not track emergency department visits or mortality. However, the MedPAC 2018 report concluded that HRRP reduced readmission rates without an increase in observational stays, emergency department visits, or mortality.19,20

From a program implementation standpoint, there were not enough available appointments to accommodate all stroke/TIA patients discharged home in a timely manner. Since then, another APRN joined the team, and the clinic now occurs 1.5 days per week, tripling available appointment slots. Another obstacle was clinic appointment scheduling contingent on referrals or calls to the neurology secretary. Needless to say, this was inefficient. Now, an RN stroke navigator ensures all homebound stroke/TIA survivors are scheduled and reminded of their clinic appointment, among other duties.


An APRN-led transitional care clinic for stroke and TIA survivors discharged home can be implemented with limited resources. The results suggest that the APRN-led transitional care stroke clinic has a positive impact and may reduce 30-day hospital readmissions in stroke/TIA survivors. Similar findings in diverse cohorts and hospital systems would be compelling.


1. Yang Q, Tong X, Schieb L, et al Vital signs: recent trends in stroke death rates—United States, 2000-2015. MMWR Morb Mortal Wkly Rep. 2017;66(35):933–939.
2. Ovbiagele B, Goldstein LB, Higashida RT, et al Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. Stroke. 2013;44(8):2361–2375.
3. Lichtman JH, Leifheit-Limson EC, Jones SB, et al Predictors of hospital readmission after stroke: a systematic review. Stroke. 2010;41(11):2525–2533.
4. Burke JF, Skolarus LE, Adelman EE, Reeves MJ, Brown DL. Influence of hospital-level practices on readmission after ischemic stroke. Neurology. 2014;82(24):2196–2204.
5. Condon C, Lycan S, Duncan P, Bushnell C. Reducing readmissions after stroke with a structured nurse practitioner/registered nurse transitional stroke program. Stroke. 2016;47(6):1599–1604.
6. Haynes HN, Gallek MJ, Sheppard KG, Drake KW, Ritter LS. Transitions of care for stroke and TIA. J Am Assoc Nurse Pract. 2015;27(10):558–567.
7. Lichtman JH, Leifheit-Limson EC, Jones SB, Wang Y, Goldstein LB. 30-Day risk-standardized mortality and readmission rates after ischemic stroke in critical access hospitals. Stroke. 2012;43(10):2741–2747.
8. Poston KM, Dumas BP, Edlund BJ. Outcomes of a quality improvement project implementing stroke discharge advocacy to reduce 30-day readmission rates. J Nurs Care Qual. 2014;29(3):237–244.
9. Strowd RE, Wise SM, Umesi UN, et al Predictors of 30-day hospital readmission following ischemic and hemorrhagic stroke. Am J Med Qual. 2015;30(5):441–446.
10. Thompson MP, Zhao X, Bekelis K, et al Regional variation in 30-day ischemic stroke outcomes for Medicare beneficiaries treated in Get With The Guidelines-stroke hospitals. Circ Cardiovasc Qual Outcomes. 2017;10(8):e003604.
11. White CL, Brady TL, Saucedo LL, Motz D, Sharp J, Birnbaum LA. Towards a better understanding of readmissions after stroke: partnering with stroke survivors and caregivers. J Clin Nurs. 2015;24(7-8):1091–1100.
12. Zhong W, Geng N, Wang P, Li Z, Cao L. Prevalence, causes and risk factors of hospital readmissions after acute stroke and transient ischemic attack: a systematic review and meta-analysis. Neurol Sci. 2016;37(8):1195–1202.
13. Yousufuddin M, Young N, Keenan L, et al Five-year mortality after transient ischemic attack: focus on cardiometabolic comorbidity and hospital readmission. Stroke. 2018;49(3):730–733.
14. Arsava EM, Kim GM, Oliveira-Filho J, et al Prediction of early recurrence after acute ischemic stroke. JAMA Neurol. 2016;73(4):396–401.
15. Bushnell CD, Duncan PW, Lycan SL, et al A person-centered approach to poststroke care: The COMprehensive Post-Acute Stroke Services Model. J Am Geriatr Soc. 2018;66(5):1025–1030.
16. Krumholz HM. Post-hospital syndrome: an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100–102.
17. Puhr MI, Thompson HJ. The use of transitional care models in patients with stroke. J Neurosci Nurs. 2015;47(4):223–224.
18. Webster F, Saposnik G, Kapral MK, Fang J, O'Callaghan C, Hachinski V. Organized outpatient care: stroke prevention clinic referrals are associated with reduced mortality after transient ischemic attack and ischemic stroke. Stroke. 2011;42(11):3176–3182.
19. Medicare Payment Advisory Commission. Report to the Congress: Medicare and the health care delivery system. Published 2018. Accessed October 18, 2018.
20. McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation. 2015;131(20):1796–1803.
21. Rantz MJ, Popejoy L, Vogelsmeier A, et al Reducing avoidable hospitalizations and improving quality in nursing homes with APRNs and interdisciplinary support: lessons learned. J Nurs Care Qual. 2018;33(1):5–9.
22. Freburger JK, Li D, Fraher EP. Community use of physical and occupational therapy after stroke and risk of hospital readmission. Arch Phys Med Rehabil. 2018;99(1):26–34.
23. Bryant-Lukosius D, Carter N, Reid K, et al The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review. J Eval Clin Pract. 2015;21(5):763–781.
24. Donald F, Kilpatrick K, Reid K, et al Hospital to community transitional care by nurse practitioners: a systematic review of cost-effectiveness. Int J Nurs Stud. 2015;52(1):436–451.
25. Newhouse RP, Stanik-Hutt J, White KM, et al Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29(5):230–250.

advanced practice nursing; readmission; stroke; transient ischemic attack; transitional care

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