title: Care Coordination for Community Transitions for Individuals Post-stroke Returning to Low-Resource Rural Communities.
abstract: High rates of hospital readmissions have been shown within 12 months post-discharge from inpatient rehabilitation following stroke. Multiple studies coupled with our previous work indicate a need for care support for stroke survivors' transitions to the community. The Kentucky Care Coordination for Community Transitions (KC3T) program was developed to provide access to medical, social, and environmental services to support community transitions for individuals with neurological conditions and their caregivers living in Kentucky. This program assessment was conducted to determine the effectiveness of using a specially trained community health worker to support community transitions. Thirty acute stroke survivors were enrolled in this program between July 2015 and May 2016. Data collection included: incidence of comorbidities; access to healthcare, insurance, medical equipment (DME), and medications; type of follow-up education provided; and number of 30-day rehospitalizations and Emergency Department (ED) visits. Participants required navigation in their home and community transition with support in: patient-provider communication; insurance support; accessing follow-up care; education on managing chronic health conditions, the stroke process, transfers and mobility; and accessing DME and essential medications. There were no 30-day ED visits for the KC3T participants and only one 30-day hospital readmission, which was not stroke-related. Individuals returning to rural communities following a stroke require, but often don't receive, follow-up education on chronic disease management, support in navigating the healthcare system and accessing essential resources. KC3T's navigator program appears to be effective in supporting the community transitions of individuals poststroke.
authors.affiliation: Department of Rehabilitation Sciences, University of Kentucky College of Health Sciences, 208 Charles T. Wethington, Jr. Building, Lexington, KY, 40536-0200, USA. phkitz1@uky.edu.
authors.forename: Patrick
authors.initials: P
authors.lastname: Kitzman
authors.affiliation: Center for Excellence in Rural Health, University of Kentucky, Hazard, KY, USA.
authors.forename: Keisha
authors.initials: K
authors.lastname: Hudson
authors.affiliation: Appalachian Regional Healthcare, Lexington, KY, USA.
authors.forename: Violet
authors.initials: V
authors.lastname: Sylvia
authors.affiliation: Center for Excellence in Rural Health, University of Kentucky, Hazard, KY, USA.
authors.forename: Frances
authors.initials: F
authors.lastname: Feltner
authors.affiliation: Center for Excellence in Rural Health, University of Kentucky, Hazard, KY, USA.
authors.forename: Johnnie
authors.initials: J
authors.lastname: Lovins
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D006801:Humans; D007629:Kentucky / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data; D062526:Patient Navigation; D010359:Patient Readmission / Q000706:statistics & numerical data; D012307:Risk Factors; D012423:Rural Health; D012424:Rural Population; D012657:Self-Help Groups; D020521:Stroke / Q000628:therapy*; D000069341:Transitional Care
keywords: Navigation; Rural health; Stroke