High rates of hospital readmissions have been shown within 12 months post-discharge from inpatient rehabilitation following stroke. Multiple studies coupled with our previous work indicate a need for care support for stroke survivors’ transitions to the community. The Kentucky Care Coordination for Community Transitions (KC3T) program was developed to provide access to medical, social, and environmental services to support community transitions for individuals with neurological conditions and their caregivers living in Kentucky. This program assessment was conducted to determine the effectiveness of using a specially trained community health worker to support community transitions. Thirty acute stroke survivors were enrolled in this program between July 2015 and May 2016. Data collection included: incidence of comorbidities; access to healthcare, insurance, medical equipment (DME), and medications; type of follow-up education provided; and number of 30-day rehospitalizations and Emergency Department (ED) visits. Participants required navigation in their home and community transition with support in: patient-provider communication; insurance support; accessing follow-up care; education on managing chronic health conditions, the stroke process, transfers and mobility; and accessing DME and essential medications. There were no 30-day ED visits for the KC3T participants and only one 30-day hospital readmission, which was not stroke-related. Individuals returning to rural communities following a stroke require, but often don’t receive, follow-up education on chronic disease management, support in navigating the healthcare system and accessing essential resources. KC3T’s navigator program appears to be effective in supporting the community transitions of individuals poststroke.

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Published in Journal of Community Health, v. 42, issue 3, p. 565-572.

© Springer Science+Business Media New York 2016

The copyright holder has granted the permission for posting the article here.

This is a post-peer-review, pre-copyedit version of an article published in Journal of Community Health. The final authenticated version is available online at: https://doi.org/10.1007/s10900-016-0289-0.

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The pilot study was originally funded through a small grant through the University of Kentucky Center for Clinical and Translational Sciences (NIH CTSA UL1TR000117). The KC3T program is currently funded through a collaborative agreement between the Appalachian Regional Healthcare and the University of Kentucky.