UofL Hospital continues innovation for best stroke care with patient follow-up pilot

The University of Louisville Hospital – Comprehensive Stroke Center is piloting a new effort to provide follow-up care for stroke patients after they leave the hospital. UofL Hospital’s U Care is designed to support continued recovery for patients following their inpatient stay.

“We want to ensure that patients have all they need when they leave the hospital to successfully continue their recovery at home – education, medications and a phone number to call if there are any problems,” said Paula Gisler, administrative director of the UofL Hospital Stroke Center.

U Care was developed in partnership with Lacuna Health, a subsidiary of Kindred Healthcare, to follow up with patients after they leave the hospital. Registered nurses with U Care reach out to patients by phone on a regular schedule to monitor the patients’ recovery progress, check their medications, ensure they have made appropriate follow-up appointments and answer any questions or health concerns that arise. The nurses have access to the patients’ health records and can escalate any concerns to hospital staff or physicians if a patient requires further clarification or intervention. The program pilot, which began in June, will follow 250 stroke patients for 45 days after discharge, whether they went home or to a rehab facility for recovery.

Patients and their families also may call the nurses at U Care if they have questions or concerns related to their stroke. In addition, the program will record levels of patient satisfaction at the rehab centers.

“At UofL Hospital, we continually strive for excellence in the acute treatment of stroke patients,” said Kerri Remmel, MD, PhD, medical director of the UofL Hospital Stroke Center and chair of the UofL Department of Neurology. “U Care adds the vital step of thoroughly programmed follow-up with stroke patients to ensure they continue recovery, avoid unnecessary readmission to the hospital and prevent a second stroke.”

Lacuna Health administers U Care for the hospital, and is monitoring its success to make further improvements and to adapt the program to other patient populations.

“We are thrilled to support the University of Louisville Hospital – Comprehensive Stroke Center’s U Care program with our RN-led clinical AfterCare model. Patients and their caregivers need more resources and ongoing support when managing the transition from a hospitalization to another setting or home. We look forward to implementing this model and future programs to help UofL Hospital provide a differentiated patient experience for the communities it serves,” said Brian Holzer, MD, MBA, CEO of Lacuna Health.

U Care is yet another innovation in quality stroke care by the staff at the UofL Hospital, the first hospital designated as a comprehensive stroke center in Kentucky by the Joint Commission. In addition, UofL Hospital once again has been awarded the top level of distinction by the American Heart Association/American Stroke Association with the Get With The Guidelines® Target: Stroke Elite Plus, Gold Plus award. The award recognizes the hospital’s success in providing the most appropriate stroke treatment according to nationally recognized, research-based guidelines based on the latest scientific evidence. Hospitals must achieve 85 percent or higher adherence to all Get With The Guidelines-Stroke achievement indicators for two or more consecutive 12-month periods and achieve 75 percent or higher compliance with five of eight Get With The Guidelines-Stroke Quality measures to receive the Gold Plus Quality Achievement Award.

UofL Hospital has achieved the highest recognitions for stroke care for 12 years.