Eastern Kentucky stroke survivors in community support program get the support they need to keep from returning to the hospital

Early results of a new program show that stroke patients who get support with education, resources and care coordination after they leave the hospital are less likely to be readmitted, according to the University of Kentucky.

Community Transition Program Stroke Support Group (UKNow image)

The Community Transition Program, which serves Perry and surrounding counties in Eastern Kentucky, has provided this type of support to 23 stroke survivors since July 2015 by connecting a “patient navigator” with stroke survivors before they leave the hospital. The navigator communicates with the survivor during the next year or longer, helping them to better understand their health-care and insurance needs, and connecting them with community resources, including a support group.

“A lot of people who have had a stroke get home and they feel like they’re lost. They don’t know what to do, they don’t know who to contact for questions, they don’t get all the education they need about stroke and co-morbidities,” Keisha Hudson, the patient navigator for the program, said in a UK news release. “They get lost in the system, and therefore some of them end up back in the hospital. Our goal is to keep them out.”

And while the most recent data are still being finalized, Patrick Kitzman, director of the program, said its readmission rates are well below comparison groups. As of late January, none of the stroke survivors who participated in the program have been readmitted for stroke-related issues.

“It’s showing that our population is very involved and requires a lot of help,” Kitzman said. “Standard of care is that you send them home and one week later you check on them, and then that’s it. But we’re showing that you need to be much more hands on. A lot of data now show that these folks require support for an extended period of time, and our data is bearing that out at as well.”

After a pilot period, the program has been funded since July 2015 by Appalachian Regional Healthcare and the UK Center for Excellence in Rural Health.

Lloyd Cornett, a stroke survivor from Slemp, said he “couldn’t have survived” without the program as he had gotten so “downhearted” because people were telling him he would have another stroke within a year, and it would be worse than the first one. He said Hudson and the physicians helped him understand that that wasn’t true.

“They sit you down and they’ll talk to you, tell you every little thing to look for, what to do, and how to do it. I’m a diabetic, and they have people come to the stroke meetings to talk about that, or blood pressure or health things we need to know. I just can’t say enough about how good they are,” said Cornett, whose stroke made him unable to speak and numb on his right side.

The program has led to some life-saving interventions, including: discovering one patient in a diabetic coma, finding an infected surgical site, and directing medical care for a patient who was breathing heavily during a telephone call and was hospitalized with dangerous levels of fluid on her lungs.

Kitzman said such close-call stories show the need for coordinated care, especially in Kentucky, which ranks 47th for incidence of stroke. He noted that stroke rates are higher in Appalachian Kentucky.

In the region, Kitzman said, many stroke survivors have some of the greatest needs for care and some of the heaviest financial burden, and need dedicated support to navigate the health-care system.

Kitzman said there is a need to have programs like this for other conditions and in other geographic areas.

“The more that we do this program, the more I’m so absolutely convinced that the only way we can have proper support for people whose conditions are so complex is to have programs like this,” Kitzman said. “They have the fewest resources available to them, and they’re the furthest away from specialized care and from what they need. Many of them don’t know what resources exist. They need someone to walk them through this change in their life. And you absolutely need someone from their community who knows where all the little pockets of support exist.”

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