To increase the number of stroke clinic patients who appoint health care proxies (HCPs) while in clinic with the ultimate goal of reducing patients without HCPs admitted to the inpatient stroke service

There are approximately 800,000 strokes in the US every year, with as many as one quarter being recurrent strokes.  Within 5 years of a first stroke, the risk of another stroke increases by as much as 40%, often with a higher rate of death or severe disability.  On average, nearly 37% of Americans have advanced directives for end-of-life care and 33% have appointed health care power of attorney. Patients are often admitted to Boston Medical Center Stroke Service with devastating infarcts, many with new-onset aphasia, who are unable to appoint HCPs.  Patients endure prolonged hospitalization awaiting guardianship consequently delaying important stroke rehabilitation.

Review of stroke outpatient clinic data over one month for two separate providers showed that only 38% of patients have appointed HCPs.  We developed a system that allows medical assistants to flag patients who do not have an appointed HCP so that the process can be completed during the outpatient visit with the stroke provider.

Following our intervention pilot program with 62 stroke clinic patients, we were able to increase proportion of patients with appointed HCPs to 48%.  Following discussions with medical assistants and stroke clinic providers, barriers to increasing proportion of patients with appointed HCPs included time constraints and patient reliability reporting HCP status.

Ideally, appointing HCPs in stroke clinic will become standard of care, with the ultimate goal of fewer patients being admitted to the stroke inpatient service with guardianship being a barrier to discharge. Next steps will include expanding to other clinics, establishing online format for HCP form, and ultimately dedicated neurology social worker in outpatient setting.