Nurse Practitioner FT Day Neuro CBMC

About the role

The Transitions of Care (TOC) Stroke Nurse Practitioner is responsible for providing comprehensive inpatient and outpatient care for patients discharged from the Comprehensive Stroke Center with diagnoses of ischemic stroke, transient ischemic attack (TIA), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and other cerebrovascular disorders. This role serves as a key member of the stroke team, ensuring continuity of care following hospitalization, supporting secondary stroke prevention, reducing readmissions, and improving patient outcomes.

Responsibilities

• Conduct post-discharge follow-up phone calls and visits for patients with stroke, TIA, ICH, SAH, and other cerebrovascular diagnoses.
• Perform comprehensive neurological assessments and ongoing management of stroke-related conditions.
• Review hospitalization, diagnostic testing, medications, and treatment plans.
• Perform medication reconciliation and adjust treatment plans as appropriate.
• Reinforce secondary stroke prevention strategies and risk factor modification.
• Identify complications, barriers to recovery, and patient care needs.
• Coordinate diagnostic testing, specialty referrals, and follow-up care as indicated.
• Escalate clinical concerns to the supervising vascular neurologist when appropriate.
• Facilitate timely transitions from inpatient to outpatient care.
• Collaborate with inpatient teams, outpatient providers, primary care physicians, specialists, rehabilitation facilities, home care agencies, and community resources.
• Identify and address barriers to care, medication adherence, and follow-up compliance.
• Participate in stroke readmission reduction initiatives and quality improvement projects.
• Provide education to patients and families regarding stroke recovery, warning signs, medications, and risk factor management.
• Reinforce BEFAST stroke recognition and emergency response activation.
• Participate in community education programs, stroke awareness events, support groups, health fairs, and outreach initiatives sponsored by the Comprehensive Stroke Center.
• Education and community outreach.
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• Education and community