Nurse Practitioner Study Improves Vital Access to Care for Stroke Patients

Readmission Rates Dramatically Improved

Stroke patients in the North Country are avoiding return trips to the hospital in part due to the work of a Nurse Practitioner at The University of Vermont Health Network-Champlain Valley Physicians Hospital (CVPH).

Senior Nurse Practitioner in Stroke/Neurology Sarah Baskind, who earned her Doctorate of Nursing Practice from George Washington University in the spring of 2022, knew that readmission rates at CVPH for patients suffering a stroke or transient ischemic attack (TIA) were on the rise. At the same time, it was difficult for patients in northern New York to access outpatient neurology care, with neurology clinic appointments often not available for more than a month due to substantial demand.

“It’s just so busy, and with limited resources and staff, it’s hard to get patients in as quickly as we’d like,” Baskind offered. “But evidence shows us that patients being seen by a neurology provider soon after a stroke or TIA improves outcomes and helps prevent additional events.”


Baskind saw an opportunity to begin addressing the issue by improving the coordination and quality of care for patients once they left the hospital. She began a study that implemented a Transitional Care Model (TCM) similar to one in place at The University of Vermont Medical Center in Burlington.

“We work really closely with the stroke team in Burlington, and so following their lead made a lot of sense. It also helps make things more uniform across all Network hospitals,” Baskind explained.

Adapted to fit the needs of CVPH patients while working within the hospital’s resources, the TCM included:

  • Patient education materials.
  • Scheduling an appointment with a primary care provider (PCP) within 2 weeks of discharge.
  • 7-day post-discharge follow-up phone call and survey with the patient.
  • 30-day post-discharge follow-up phone call and survey with the patient.


Baskind’s study was conducted over three months in the fall of 2021, and the impact was immediate. Before the TCM was implemented, the mean 30-day readmission rate for stroke and TIA patients at CVPH was around 35 percent. After implementation, the readmission rate dropped to 3.7 percent over the 3-month time period. Baskind said that while the sample size was small, the results were still statistically significant.

“I think it’s a very proactive type of attitude to have. This is an opportunity to bridge a gap we have with our patients and make a difference in the care they receive,” CVPH Clinical Quality Manager Colleen Bell, BSN, RN said.

“It’s a great starting point,” Baskind added. “This shows us that this is something we can pursue even further.”


She also noted how well her efforts were received by patients when she followed up with phone calls at the 7-day and 30-day time periods.

“They really appreciated that contact from someone from the hospital. They felt like they were getting the care they needed.”

Through her contact with patients, Baskind learned some of them did not have stroke education materials the hospital provided when they went home. As a result, she went over that information on the phone with each of those patients and mailed the educational materials to their homes. She also ensured each patient she contacted had a PCP appointment scheduled shortly after discharge.

“Because of Sarah’s work, we were able to further support the patient after transitioning home. And it provided more opportunities to address issues coming up, answering their questions, talking about medications and prioritizing the care the patient needed. She got ahead of the game with the patients she talked to, and that made a real difference for them,” Bell explained.


Baskind continues to work on implementing the Transitional Care Model in a more permanent fashion, as resources and staffing allow. She is also now seeing some stroke patients at CVPH Neurology after they are discharged, helping open up quicker access she and the entire stroke team at the hospital are striving for.

“Patients are responding really well to this. And it’s amazing to see that kind of impact. The evidence shows this could be a significant practice change that benefits them. And we’re getting insight on ways we can improve and open up access even further. The stroke team at CVPH is doing a lot of great work, and I’m looking forward to seeing what more we can do for stroke and TIA care in the North Country.”


Baskind’s study and implementation of a TCM is part of the tireless work being done at CVPH to provide stroke care that is making a difference in the lives of stroke patients and their families, and it’s getting noticed at the national level. This year, the hospital earned the American Heart Association’s (AHA) Get With the Guidelines – Stroke Gold with Target: Type 2 Diabetes Honor Roll. It is the second year in a row CVPH has been honored for stroke care by the AHA.