Improving Coordination and Transitions of Care in Stroke Patients

Study Overview
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Brief Summary
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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.

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

Conditions
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Stroke, Transient Ischemic Attack

Intervention / Treatment
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* Other: Nursing care model


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Attending nurse model<br>The attending nurse model of in-hospital care delivery aims to improve patient understanding, shared decision making, medication adherence, and reduce early readmissions after discharge to improve quality of life. On the inpatient stroke unit, the attending nurse will take ownership of essential aspects of an individual stroke patient's care, education, and transition out of the hospital. To further contribute to the patient's plan of care, the attending nurse will be present on daily teaching rounds. | Other: Nursing care model<br>* Subjects will be randomized into either the attending nursing model of care vs the standard nursing model<br>|
| No Intervention: Conventional inpatient nursing care<br>Standard of care nursing care patients receive while inpatient | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Stroke Patient Education Retention Tool | measures patient knowledge about stroke | 90 days | 
| Medication Compliance | medication adherence measurement | 90 Days |