JSTTEP: An interprofessional intervention to reduce early risk after hospitalization for stroke

Background: The transition period from hospital to home is a highly vulnerable time for patients after stroke COVID-19 restrictions have exacerbated safety concerns, stressed the health care system, and put patients at high risk after discharge Here we describe pilot results from the Joint Stroke Transitional Technology-Enhanced Program (JSTTEP) designed to reduce post-stroke complications, avoid hospital readmission, and enhance recovery Methods: JSTTEP is a novel, interprofessional program for patients discharged from the Johns Hopkins Comprehensive Stroke Center In the first weeks after hospital discharge, stroke patients complete a series of multidisciplinary telemedicine visits to (1) reduce the risks of adverse events in the transition from hospital to home, and (2) develop a plan to facilitate a full recovery The first joint visit is with stroke neurology and physical therapy for risk mitigation, and the second is with physiatry and occupational therapy for a recovery plan Patients and caregivers participate in an interactive, online group education session covering topics about vascular risk factor modification, nutrition, exercise, fall prevention, and self-management skills Results: In the first 4 months of the program, 50 patients were enrolled Average age was 61 years;26/50 (52%) were women, 23/50 (46%) were African American, and mean baseline NIHSS was 5 4 Of those 45/50 (90%) completed their visit, with 4/50 (8%) requiring conversion from video to phone visit Unexpected 30-day hospital readmission rate was 3/50 (6%), one of whom was readmitted due to neurological issues identified during the JSTTEP appointment Interpreter services were utilized for 5 completed video visits (Arabic, Mandarin, Spanish, Twi, Urdu) Patients reported the ability to include family members remotely in the visit as an advantage Conclusions: The data demonstrate the feasibility and potential benefit of an interprofessionalstroke telemedicine program designed to enhance post-stroke recovery JSTTEP increased accessto post-hospital care and reduced risks for adverse outcomes The ongoing benefits and scaling ofsuch a clinic will rely on permanent legislative and insurance changes to support such a care model