Feasibility of a Telemedicine-Based Principal Illness Navigation (PIN) Service for Complex Populations Following Hospital Discharge After Acute Stroke

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Background Principal Illness Navigation (PIN) services may play an important role in helping patients through important transitions in care following acute hospitalization. We evaluated a novel PIN telemedicine approach to understand the feasibility of providing these services to diverse patient cohorts. Methods A single-arm, retrospective observational study of Kandu Health’s post-acute PIN service was conducted in patients experiencing ischemic or hemorrhagic stroke in California and New Jersey. The technology-enabled program offered remote healthcare support led by occupational therapists and licensed clinical social workers that was tailored to individual patient needs to facilitate transition to community settings post-discharge. Barriers to recovery were addressed through patient education, one-on-one guidance, and specialized referrals. Patient outcomes were assessed through in-app assessments and clinician-assessed modified Rankin Scores conducted via video consultation. Readmissions were monitored through both patient reporting and admission/discharge/transfer feeds from health information exchanges. Results A total of 111 patients were enrolled between June 22, 2022 and January 11, 2024. Patients were onboarded an average of 29 ± 40 days (median 18, IQR 8-32) after acute care hospital discharge and spent an average of 81 ± 21 days (median 90, IQR 75-90) in the program. During that time, the average enrollee spent 333 ± 156 minutes (median 350, IQR 205-435) of 1:1 time interacting with their dedicated navigator, and navigators spent an additional 113 ± 87 minutes (median 95, IQR 61-140) per patient on care coordination and curriculum curation. Patients with 5 or more social determinants of health (SDOH) needs required over 50% more navigator time than those without any SDOH needs. Within 6 weeks of hospital discharge, 8.5% experienced an inpatient hospital all-cause readmission that was not associated with race, ethnicity, or SDOH. Conclusions High rates of enrollment and extensive patient engagement in both navigator-facilitated and self-directed program elements can be achieved using the Kandu program. Our findings indicate that telemedicine facilitated, app-supported PIN is feasible to deliver following acute stroke discharge across diverse ages, races, ethnicities, functional status (mRS), and social needs.

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