To determine care gaps and 30-day readmission rates among stroke patients discharged home from a safety net hospital.

112 eligible patients were contacted; mean age 64 years, 54% female, 67% Black. 37(36%) were unreachable, 44(42%) completed the program and 23(22%) partially engaged in the TOC program. We identified 26 patients (26/67, 39%) with a combined total of 55 care gaps. The most common care gaps were lack of primary care (PCP) follow-up (20/55, 36%), followed by failure to monitor blood pressure at home (18/55, 33%), non-adherence to prescribed medications (9/55, 16%), and transportation challenges (3/55, 6%). The overall readmission rate was 23%. There was no difference in the 30-day readmission rate between TOC participants and non-participants. Most common reasons for readmission were headache (50%), stroke-like symptoms (17%), hypertension (8%), and GI bleeding (8%).

We identified several care gaps during the early discharge period. Interventions planned to address care gaps include updating phone numbers prior to discharge, arranging patient transportation to follow-up appointments, scheduling PCP appointment, using meds to bed program prior to discharge, and teach back method for medication adherence. We did not find a difference in the readmission rate, likely due to the small sample size.