Abstract Body: Introduction
The transitional period from hospital discharge to the community for stroke survivors is a vulnerable time as patients navigate healthcare systems with their new impairments. Stroke related readmission rates are highest within the first year of the index stroke. This institution created the Stroke Transitions Program to improve patients’ healthcare after hospital discharge for a stroke.

Hypothesis
Stroke survivors enrolled in the Stroke Transitions Program reduces their 1 year hospital readmission rates.

Methods
In this retrospective study, electronic medical records were reviewed for patients hospitalized for ischemic or hemorrhagic strokes at Kaiser Permanente San Francisco Medical Center between April 1, 2017 to March 31, 2023. Patients with a modified Rankin score of 3-5 were offered enrollment in the Stroke Transitions Program (intervention group). The control group included patients not enrolled in the program. The program involves telephone visits with a stroke-specialized nurse within 1 week after discharge and 3 months post-discharge. During the visits, the nurse promotes medication adherence, ensures follow up appointments are scheduled, screens for stroke related complications such as falls, spasticity, memory loss, and depression, and provides stroke education. Patients were also provided with the stroke nurse’s direct contact information to help navigate the healthcare system. Outcomes were 1 year hospital readmission rates by all-cause and due to repeat stroke.

Results
Patients in the intervention group and control group were similar in age, BMI, race, smoking status, as well as rates of hypertension, diabetes, hyperlipidemia, atrial fibrillation, and history of prior stroke, with the exception of discharge rate to skilled nursing facility was higher in the intervention group (p=0.02). The intervention group had a significantly lower rate of 1 year hospital readmission due to any cause (62.1% vs 69.3%, p=0.04). The two groups did not differ significantly in 1 year hospital readmission rates due to repeat stroke.

Conclusions
The implementation of the Stroke Transitions Program may have contributed to significantly reduced 1 year hospital readmission rates for stroke survivors, particularly considering that although more patients in the intervention group were discharged to a SNF which have higher hospital readmission rates, the intervention group showed significantly lower readmission rates.