TeleStroke/Vascular Neurology Patient Navigator Program

  • Need: Improve post-hospital stroke care access in order to improve physical function and well-being for stroke patients living in a 6-county area in rural Minnesota.
  • Intervention: Implementation of an evidence-based patient navigator program paired with telehealth services for post-hospital care of rural stroke patients.
  • Results: In addition to other successes, more than 120 individuals enrolled in the navigator program, the Modified Rankin Score assessments at baseline and 6 months showed functional improvements.


Promising (About evidence-level criteria)


According to a 2017 Centers for Disease Prevention and Control (CDC) report, “reduction in stroke mortality is recognized as one of the 10 great public health achievements of the 20th century.” In survivors, stroke is still a leading cause of significant long-term disability and public health experts emphasize monitoring the efficiency and effectiveness of the “stroke systems of care,” the succession of care settings involved with stroke care. This system includes post-hospital stroke care and rehabilitation.

Post-stroke recovery needs vary between patients, but usually require follow-up with multiple specialties: speech therapists, physical therapists, occupational therapists, primary care providers, neurologists, and behavioral health providers. Patients and families also need to connect with agencies addressing disability concerns and issues associated with other health-related social determinants.

To improve post-hospital stroke care in a 6-county area in rural Minnesota, CentraCare Health-Long Prairie Health System led the implementation of the TeleStroke/Vascular Neurology Patient Program. This effort included work by a consortium of partners from 7 home health agencies and 9 hospital/clinic organizations, all rural except the urban healthcare organization with a Primary Stroke Center certification in St. Cloud, Minnesota. All home healthcare agencies were Medicare Certified Home Health and held Minnesota Department of Health certifications. Counties included were Todd, Stearns, Pope, Wadena, Swift, and Douglas. The program followed patients for 6 months.

In addition to providing self-care management assistance for those with stroke, 6 objectives were key to the program’s goal:

  • Increase patient access to a virtual neurologic examination by a neurology provider at the urban stroke center
  • Reduction of post-stroke disability
  • Improvement of quality of life among patients after hospital-based acute stroke care
  • High patient satisfaction with their post-hospital care
  • Minimize readmissions
  • Completion of modified Rankin Scale (mRS) and the depression scale assessments at designated intervals of 30 and 90 days

An important part of the program was ensuring neurology follow-up at 30 and 90 days post-acute stroke event. This was accomplished through synchronization of the availability of the patient, hospital-based nursing staff to assist with the exam in the selected hospital’s videoconference-equipped consultation room, and the St. Cloud-based neurologist. Patients usually had their exam at the rural hospital where they received their original acute stroke care. Because these needed evaluations are performed by urban-based specialists, the virtual availability is important for rural stroke survivors.

The program’s staff included a program director and a patient navigator, the latter a registered nurse case manager who focused on helping patients access individualized culturally competent care. The navigator reviewed participating hospitals’ TeleStroke list in order to connect by phone with potential enrollees within 7-10 days of acute care discharge. After the enrollment of willing patients, the navigator also connected with primary care providers and home health workers, considered the “legs in the community” for the project.

The program partners’ leadership worked to create program sustainability, in addition to solidifying a comprehensive post-hospital stroke care network.

This project received support from the Federal Office of Rural Health Policy’s (FORHP) 2015-2018 Rural Health Care Services Outreach Grant Program.

Telehealth room
Hospital nursing staff, patient, and on the computer screen, the remote consultant, all present in a rural healthcare organization’s telehealth room.

Services offered

Navigator and home health services for patients and caregivers:

  • Medication assistance
  • Durable equipment needs assistance
  • Patient-centric and caregiver-centric community services assistance, such as helping to connect with support groups and respite care
  • Assistance with establishing a medical home
  • Disease-specific education for patient and caregiver, for example, blood pressure monitoring, exercise, nutrition, and other information
  • Medical appointment assistance
  • Referrals for any needed speech, physical, occupational, and respiratory therapies
  • Assistance with follow-up suggestions given at medical appointments

Navigator-specific patient services:

  • Patient follow-up by phone at 3 months, 6 months, and as needed during which care plan adherence is reviewed, such as needed follow-up labs, life style choices
  • Health-Related Quality of Life assessment conducted at enrollment and before program discharge at 6 months.


More than 120 patients enrolled in the program. Program-specific measures revealed:

  • 77% completed neurology follow-up, the majority by using a telehealth connection
  • mRS assessment revealed an average disability decrease of 53%
  • Less than 9% all-cause readmission rate

Additional results:

  • 95% preferred the virtual neurology evaluation over travel to the stroke center
  • 82% expressed confidence in the virtual evaluation quality versus the quality of care expected from a face-to-face visit

Program success has:

  • Encouraged the stroke center’s neurosciences department to review and adopt the program
  • Led to CentraCare Health’s addition of cardiology, urology, oncology, neurosurgery, and infectious disease specialties to their telehealth services

This program used the following evidence-based models and information:


Lack of electronic health record interoperability created difficulty in:

  • Sharing information between hospitals, clinics, and stroke center
  • Synchronization of multiple appointments

Contact Information

Daniel J. Swenson, MBA, FACHE, Chief Executive Officer
CentraCare Health-Long Prairie Health System