Abstract Body: Background and Purpose: Stroke patients discharged home face significant vulnerabilities in the immediate post-discharge period. Our Comprehensive Stroke Center identified critical gaps in post-discharge care, including inconsistent follow-up timing and a high rate of missed appointments. This initiative, led by Advanced Practice Providers (APPs), aimed to refine the post-discharge process to enhance care quality and reduce missed follow-ups.

Methods: We introduced a streamlined follow-up process for stroke patients discharged home, adhering to the Centers for Medicaid and Medicare (CMS) Transitional Care Management (TCM) model. An Advanced Practice Provider, specifically a Nurse Practitioner (NP), conducted inpatient rounds, coordinated follow-up appointments prior to discharge, and initiated contact with patients within 24-48 hours. Follow-up visits were scheduled with the outpatient stroke NP within 7 to 14 days, either in the clinic or via telemedicine. This approach, compliant with CMS TCM requirements and billable under TCM codes, was evaluated over a seven-month period, with a focus on clinic no-show rates and reimbursement compared to traditional discharge practices.

Results: The TCM model, managed by APPs, resulted in a 3% no-show rate, significantly lower than the 14% rate for patients discharged without TCM. All patients under the TCM model had a scheduled post-discharge follow-up appointment, compared to only 9% of those discharged without TCM who lacked a scheduled stroke follow-up. Additionally, appropriate use of CMS TCM codes led to higher reimbursement and increased departmental revenue.

Conclusions: The APP-led initiative aligned our discharge process with the CMS-recognized TCM model, improving the scheduling of post-discharge follow-up appointments, reducing clinic no-show rates, enhanced departmental revenue, and strengthening collaboration between inpatient and outpatient APPs.