Abstract WP095: Centralized Post-Hospitalization Stroke Care through a Multidisciplinary Stroke Clinic: A Solution for a Large Healthcare System

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Background: Emory Healthcare implemented a structured, multidisciplinary stroke clinic system led by stroke prevention and rehabilitation physicians supported by physical therapy, neuropsychology and geriatric medicine. This model is designed to enhance post-stroke care through improved risk factor control, access to specialty services, and reduced recurrence.This study evaluated the impact of a comprehensive multidisciplinary stroke systems-of-care model in a real-world setting. Methods: We retrospectively analyzed patients with ischemic stroke, ICH, SAH, or TIA discharged from six Emory Healthcare stroke centers and seen in a centralized stroke clinic before (October 1, 2022–December 31, 2023) and after (January 1, 2024–April 30, 2025) implementing a structured multidisciplinary care model. Clinical outcomes include time from discharge to outpatient LDL<70 mg/dL and SBP <130 mmHg), neuropsychology, and rehabilitation evaluation are reported for discharges from the Comprehensive Stroke Center (CSC) and systemwide. Results: During the study period, 2451 patients (mean age 64±15 years, 59% black, 51% female, 83% ischemic stroke) were seen in the stroke clinic after hospital discharge. There was a significant increase in hospital-discharged patients seen within 90 days after implementation among CSC (Pre 31% vs Post 40%, p<0.001) and systemwide hospitals (Pre 22%, Post 29%, p <0.001). There was no significant difference in 90-day system ED revisits (Pre 16%, Post 15%, p=0.47), 90-day system readmissions (Pre 17% vs Post 19%, p=0.21) or mortality (Pre 0.8%, Post 1.9%, p=0.07). Median time from discharge to achieving outpatient LDL <70 mg/dL significantly decreased [Pre 98 days [IQR: 41-221] vs. Post 67 days (IQR: 51-134), p=0.001] as did time to achieving systolic BP <130 mmHg [154 days (IQR: 56-368) vs 108 days (IQR: 35-179), p=0.002]. Post-implementation 372 patients underwent neuropsychology testing. Also, rehabilitation evaluation and referrals increased by 42%. During the study period Emory Clinic ranked among the top 5 national enrollers for two NIH StrokeNet prevention trials. Conclusion: A centralized multidisciplinary outpatient stroke clinic represents an effective systems-based approach to achieving rapid risk factors control while providing cognitive and rehabilitation resources for discharged patients in a structured environment. This stroke clinic model can achieve high enrollment targets for stroke prevention and rehabilitation clinical trials.

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