Abstract Body: Background and Purpose: Patients discharged home after a stroke are particularly vulnerable during the immediate post-discharge period. We identified significant gaps in post-discharge care for stroke patients at our Comprehensive Stroke Center, including inconsistent follow-up timing and a high rate of missed appointments. This initiative aimed to enhance the post-discharge process to improve care quality and reduce missed follow-ups.

Methods: We implemented a streamlined follow-up process for stroke patients discharged home, aligning with the Centers for Medicaid and Medicare (CMS) definition of the Transitional Care Management (TCM). A Nurse Practitioner (NP) conducted inpatient rounds, coordinated follow-up appointments before discharge, and contacted patients within 24-48 hours. Patients were seen by the outpatient stroke NP within 7 to 14 days, either in clinic or via telemedicine. This process, compliant with CMS requirements and billable under TCM, was evaluated over seven months, focusing on clinic no-show rates and reimbursement compared to standard discharge practices.

Results: Patients discharged home under our TCM model had a 3% no-show rate, significantly lower than the 14% observed in those discharged without TCM. All patients discharged home with TCM had a post-discharge follow-up appointment scheduled compared to 9% of patients discharged home without TCM who had no scheduled stroke follow-up. Additionally, using the appropriate CMS codes for TCM resulted in higher reimbursement and increased revenue compared to standard follow-up billing.

Conclusions: Implementing this initiative aligned our discharge process with the CMS-recognized TCM model, improved scheduling of post-discharge follow-up appointments, reduced post-discharge clinic no-show rates, and increased departmental revenue.