Stroke is the 2nd leading cause of death and the 3rd leading cause of disability worldwide.In the United States, a stroke occurs every 40 seconds, and patients and caregivers face challenges from limited communication and collaboration, changing personnel, and differing geographies for stroke care. Following hospital discharge, care often occurs reactively through in-clinic visits and fails to effectively manage conditions and risk factors that increase recurrent stroke risk. 

To address this, an innovative, technology-enabled Integrated Stroke Practice Unit (ISPU) care model was implemented at Ochsner Medical Center in New Orleans, Louisiana. Supported by a Centers for Medicare and Medicaid Services (CMS) Health Care Innovation Award (#1C1CMS331043; PI: KGaines), this comprehensive care redesign combined an acute and in-hospital component (Stroke Central) with a home- or skilled nursing/rehabilitation facility-based, outpatient component (Stroke Mobile). Registered Nurse and Lay Health Educator Care Teams proactively followed patients (n=500+ seen ≥1 time from February 2013-December 2015) and caregivers post-stroke to monitor recovery and risk factor management and provide education and support. As part of this initiative, two in-depth, structured interviews and three focus groups were held with patients (n=9) and caregivers (n=5) to discuss their stroke care experiences as part of this ISPU. This presentation will detail their reported transitional and supportive needs, care system gaps, and ISPU impact and satisfaction, as well as describe the ISPU care model.

EXPERIENCES IN STROKE CARE AND RECOVERY: RESULTS FROM QUALITATIVE RESEARCH WITH PATIENTS AND CAREGIVERS AS PART OF AN INTEGRATED STROKE PRACTICE UNIT (ISPU)