Improving Coordination and Transitions of Care in Stroke Patients

Active, not recruiting

Phase N/A Results N/A

Trial Description

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.



  • Nursing care model Other
    Intervention Desc: Subjects will be randomized into either the attending nursing model of care vs the standard nursing model
    ARM 1: Kind: Experimental
    Label: Attending nurse model
    Description: The attending nurse model of in-hospital care delivery aims to improve patient understanding, shared decision making, medication adherence, and reduce early readmissions after discharge to improve quality of life. On the inpatient stroke unit, the attending nurse will take ownership of essential aspects of an individual stroke patient's care, education, and transition out of the hospital. To further contribute to the patient's plan of care, the attending nurse will be present on daily teaching rounds.

Trial Design

  • Allocation: Randomized
  • Masking: Open Label
  • Purpose: Health Services Research
  • Endpoint: Efficacy Study
  • Intervention: Parallel Assignment


Type Measure Time Frame Safety Issue
Primary Stroke Patient Education Retention tool 90 days No
Primary MMAS-4: Four question Morizky Scale 90 Days No
Secondary Questionnaire to capture patient impression of their in-hospital care, transition home and quality of life 90 days No
Secondary Stroke Impact Scale 30 days No
Secondary Proportion of readmissions 30 days No