Abstract TP395: Transition Coaching for Stroke (TRACS): Assessing Health Literacy and Readmissions

Objective: There is a critical need for tailoring transition care for stroke survivors, especially those that address health literacy. The objective of this pilot program is to provide individualized coaching for stroke risk factors at discharge, and to assess the role of health literacy on readmissions. Methods: We enrolled patients discharged home with ischemic or hemorrhagic stroke, or TIA from 9/2011 to 7/2012. Transition coaching was performed one-on-one in the hospital using a take-home packet that included review of a check list of their risk factors, medication information, instructions for stroke awareness, action with new symptoms, and post-hospital follow-up care. Materials were in large font for a 7th to 8th grade reading level, with a one-page summary for ease of reading. Data collection forms were programmed for online data entry of baseline variables (education, prior hospitalizations, health literacy) using REDcap. All cause readmissions within 30 days or longer were obtained from medical records and hospital reports. Results: 90 patients with NIHSS information were enrolled. Mean age was 63.3 yrs (std 14.3), 53% female, 69% white, 30% Black, 68% ischemic stroke, 10% hemorrhagic stroke, 20% TIA, and median NIHSS 2.0 (range 0-27). 16% were not confident filling out medical forms by themselves, 15% needed help with doctor/pharmacy materials, and 5% were not happy with the way they read. 37% preferred to learn new things by reading brochures, 14% preferred someone going over materials with them, 13% watching videos, and 12% by having someone tell them. 41% preferred alternative learning methods outside the choices provided. 22 patients were readmitted, 9 of which were within 30 days of discharge. 33% of those readmitted were not very confident or not confident at all with filling out medical forms vs 11% of those not readmitted (p= 0.026). Although attenuated after adjustment for education, low confidence with medical forms was independently associated with readmission (OR 3.235; 95% CI: 0.819-12.785; p=0.094). Conclusions: Accounting for health literacy and patient preferences for learning should be a key component in transition programs to provide appropriately tailored coaching to reduce adverse outcomes, such as readmissions.