Improving Coordination and Transitions of Care in Stroke Patients
Improving Coordination and Transitions of Care in Stroke Patients
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.
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