Abstract HUP4: Can A Remote Telehealth-based Program Support Survivors With Varying Social Needs Post-stroke?

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Introduction: There are significant and longstanding inequities in stroke prevalence and care as well as outcomes. Social determinants of health (SDOH) are known to be a risk factor in post-stroke recovery. SDOH also put individuals at higher risk for 90-day mortality. Social determinants are a significant contributor to disparities in health and specifically addressing SDOH needs may improve the health and outcomes of stroke survivors. Methods: An app-based, virtual care model was used to impact survivor quality of life and outcomes for stroke survivors and their care partners. As a part of program onboarding, the clinical navigator utilized the CMS Accountable Health Communities Health-Related Social Needs Screening Tool to assess survivor needs in five core domains including housing instability, food insecurity, transportation problems, utility needs, and interpersonal safety. As needs were identified, they were cross-walked to pre-populated community resource maps to aid the survivor in their recovery and support subsequent stroke prevention. Results: Of the (n=50) stroke survivors (median age of 62) that completed the 12-week survivor-led Navigator support program, 35% had one SDOH need, 16% had 2 SDOH needs, 16% had 3 SDOH needs, 3% had 4 SDOH needs and 28% had 5 or more SDOH needs. The most regularly identified areas of social need in the cohort were mental health (20%), financial strain (15.7%), employment (13.6%) and transportation (12.9%). These SDOH were addressed throughout the 90-day program based on individual access considerations. The 30- and 90-day all-cause readmission rates for survivors were 5% and 10%, respectively, superior to recent publications reporting 30-day unplanned readmission rates after stroke ranging from 8.7%-12.5%, and 90-day readmissions ranging from 18.9% to 20.7%. Conclusion: By assessing SDOH and providing specifically tailored post-acute resources to meet those needs, a tech-enabled platform with clinical navigator support can improve outcomes for stroke survivors with a variety of SDOH needs. Additional post-acute stroke care and targeted programming are needed to address the ongoing inequalities in the healthcare system as they relate to post-stroke care and recovery in populations with high SDOH needs.

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