Abstract NS6: Connecting the Dots; a Pharmacist-Led Care Transition Model for Stroke Patients Post-Discharge

Background/Purpose: Stroke is a leading cause of adult disability worldwide, and one in four is due to recurrence, with the highest risk within the first 30 days post-discharge. Post-discharge follow-up is key to preventing hospital readmission and recurrent stroke. At our hospital, adult ischemic stroke (IS) patients are auto-enrolled in a pharmacist-led transitions of care program. Initially, our pharmacy team completes a medication history and reconciliation. Prior authorization and financial assistance services are offered. Patients who choose to remain enrolled are discharged with a 28-day supply of their medications, followed by all subsequent medications sent in adherence pill packs. Patients then receive a call 5-to-7 days post-discharge from a pharmacist to provide counseling on secondary stroke prevention and the importance of medication adherence. The pharmacist also ensures that the patient has scheduled follow-up appointments with both their primary care provider and the stroke clinic. Methods: In this retrospective cohort study, we included adult IS patients discharged from our center between October 2021 and July 2022. We compared those who chose to continue with our services beyond discharge with patients who opted out of our program. The primary outcome is medication adherence. The secondary outcome is the readmission rate. Results: Participation in our program resulted in an adherence rate of 98.5% compared with an adherence rate of 70.2% in those who declined to participate. Readmission was lower for participation, although not significantly so. Conclusions: Our program resulted in an improvement in medication adherence and a trend towards lower readmission rates amongst participating IS patients post-discharge. Further studies should be completed to examine the additional impacts of a pharmacist-led post-discharge program on secondary stroke prevention related to surrogate markers (Blood pressure, lipids, A1C, etc.) over time.