SELLEST OSAST
The period immediately after hospital discharge is a critical yet often overlooked phase in stroke recovery, marked by both heightened vulnerability and opportunities for rapid brain repair. This episode explores the concept of transitional stroke care, emphasizing early specialist follow up, coordinated multidisciplinary support, and targeted interventions to improve outcomes and reduce complications.
In this episode, Katie Grouse, MD, FAAN, speaks with Mona N. Bahouth, MD, PhD, FAAN, author of the article "Transitional Stroke Care and the Road to Recovery" in the Continuum® June 2026 Cerebrovascular Disease issue.
Dr. Grouse is a Continuum® Audio interviewer and a clinical assistant professor at the University of California, San Francisco in San Francisco, California.
Dr. Bahouth is the medical director of the Brain Rescue Unit and an associate professor of neurology at Johns Hopkins School of Medicine in Baltimore, Maryland.
Additional Resources
Read the article: Transitional Stroke Care and the Road to Recovery
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Social Media
Guest: @MonaBahouth
Full episode transcript available here
Dr Grouse: A lot of attention has been paid to what happens within hours to days of a stroke, but are we missing an equally crucial time in our patient's recovery after their discharge? Today, I have the opportunity to interview Dr. Mona Bahouth about the latest issue of Continuum on cerebrovascular disease.
Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast.
Dr Grouse: This is Dr. Katie Grouse. Today, I'm interviewing Dr. Mona Bahouth about her article on transitional stroke care and the road to recovery. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Welcome to the podcast, and please introduce yourself to our audience.
Dr Bahouth: Thank you for having me. I'm Mona Bahouth. I'm a stroke neurologist in Baltimore, Maryland, and I'm the medical director of our brain rescue unit at the Johns Hopkins Hospital. Great to be with you.
Dr Grouse: Thank you so much. This was a very interesting article. I have to confess going into it, I really didn't know a lot about transitional stroke care and the growing sort of recognition of its importance for stroke recovery and improved outcomes. Can you tell me what the key message from this article is that you really hope that readers will take away after reading it and hopefully integrate into their own patient practices?
Dr Bahouth: Yeah. I would say if there's one overarching message, it is that stroke care has come so far over the last couple of decades. We do so much wonderful life-saving work in the first couple of hours and days after stroke, but we haven't really paid as much attention to what happens once a patient leaves the hospital with this devastating acute disease. And I would just like to say that this article allows us to shine a light on providing a little bit more of a system of care, a more structured system of care that could benefit the patient for the long term, then that will benefit a large population of patients who otherwise may have complications that could cause disability longer in life.
Dr Grouse: Now, Mona, could you tell us in a nutshell, what is transitional stroke care, and why are we needing to focus more of our attention on this to improve patient recovery?
Dr Bahouth: Yeah. Over the last few years, we've really done a wonderful job of reducing the time that a patient spends in a hospital after stroke care. But in parallel, we have not really changed anything about what we do in the outpatient setting. So, a patient tells us that they come to the hospital with this acute and very scary and disabling disease. They feel that they're the center of the universe at our stroke centers, where we're hustling around them in groups and in interprofessional teams. But then on the day of discharge, they feel that they leave the hospital, and in some of our focus groups, that they kind of go home to a, a dark bedroom where they have to process all of this sort of on their own. It's quite a transition for both patients and their care partners. And here we've been very systematic about how we structure our care in the hospital for stroke patients, but once they leave the hospital, it's been a sort of free-for-all, or the Wild West, as some of my colleagues say. So transitional stroke care is really a way to extend the care that we deliver in the stroke unit to the patient's home or to their next phase of care. We know that stroke patients have 11 handoffs from beginning to end, in average, that they experience through the course of their acute stroke. And so, what we're really trying to do is extend the, the stroke unit to the patient's home or to their next phase of care so that they feel a bit more extension of that specialty care that they were receiving in the hospital. So, it's really a structure, a system.
Dr Grouse: Now, it seems that when we're thinking about the transitional care period, that it really hinges on this idea of sort of the sensitive period of stroke recovery. What is that, and why is that so important, and why do we really need to focus on that specific time?
Dr Bahouth: There are really two reasons that this is a critical period for patients. One is that we know from work in animal models as well as other sort of human early studies that the brain really has its optimal period of efficient brain repair in the first few weeks after stroke, meaning that it's recovering after this injury and figuring out how to reroute some really important brain functions. I would say it's also a critical period because the time period after stroke is a period that all the comorbid conditions that sort of conspired to cause a stroke are sometimes destabilized. And we know that sort of just putting people back on standard regimens for their hypertension, their diabetes, their heart failure doesn't always equate to sort of long-term improved outcomes at a time that the brain itself is going through changes. So, for example, we know that blood flow is critical to the brain. That's what all the hustle is about in the hyperacute period. And for the next couple of weeks after a stroke, autoregulation remains disrupted, so typical treatments of hypertension could have negative consequences for a subpopulation of patients. This management of hypertension needs to continue for a couple of days and weeks after stroke, and therefore, if a patient is discharged from the hospital, really requires a bit more specialty input. We also know that as the brain is trying to repair during the sensitive period, this high period of efficiency, we really want to inject high-intensity, high-quality activities that really improve their recovery. But in our current system in the United States, our transition to the period of rehabilitation is really quite clunky and disrupted and doesn't often happen in a seamless way. So, a true transitional stroke care program really attempts to manage the stroke itself. The comorbid conditions that conspire to cause the stroke, and the expedition of, of rehabilitation that could really jumpstart the recovery period in a more meaningful way.
Dr Grouse: Now, you mentioned hypertension as being sort of a critical factor that can affect the patients during this transitional period or this sensitive period. What are some other factors that can really play a huge part in their long-term outcomes in this really sensitive time?
Dr Bahouth: In our transitional stroke program, in our interprofessional group, we often talk about all of the changes that a patient is required to make at the time of stroke. Typically, they stay in the hospital several days. The patient and their care partner will receive a bolus of instructions about what their new healthier life should look like, and then they're sort of sent off to sort of self-manage without really accepting that that wasn't the perfect time to teach these things. So really, it's all about sort of lifestyle improvement. How do we get into a system of medication adherence when medications are a central portion of a patient's care? It is about managing the cognitive changes that happen after stroke, whether we acknowledge them in the hospital as a main deficit or something that people realize once they get back into the groove of their usual life, and the emotional consequences of stroke for both the patient and their care partner, who are both adjusting to this very scary moment that resulted in a brain injury. So, I think that the things that are focused on are both medical in terms of, you know, what are we doing with the diabetes? Is our glucose at a target range? Have we started wearing our sleep apnea paraphernalia? Are we managing our smoking cessation as much as we should? How have we done with our low-fat diet? Are we taking our medications as prescribed, or was there some cognitive blip that caused a mistake? But also sort of the emotional support that sometimes paralyze patients into sort of saying they cannot handle this transition into a new healthier way of brain recovery.
Dr Grouse: Yes, and it sounds like when patients sort of hit that wall, they almost just give up, right? There's just so many things they have to manage. They're emotionally trying to cope, and then they may eventually get to their neurologist at some point for a follow-up, and not much has happened.
Dr Bahouth: That's a really well-put statement. Like I mentioned earlier, we had several focus groups to say, "How's our stroke center doing? How is our comprehensive stroke center doing?" And we realized that we were very comprehensive while the patient was with us, but then the experience of the patient going home was really opposite of receiving comprehensive care. You know, the patient in the hospital said they felt well-supported, surrounded, quite busy all the time, but then they did go home, and this sort of set in that they've had a stroke. And many patients told us, "I just laid in bed because I couldn't quite kind of get through the thought that this has happened to me." And so, in our prior state of our comprehensive stroke system where patients weren't seen for a couple of months after their discharge, patients would tell me, "Well, I'm fine now. But those first couple of months, I sure wasn't. You know, I was laying in bed. I was crying. I wasn't taking my medicines. I had a lot of despair and fear." Care partners would say, "I wasn't sleeping myself. I was watching to see if another stroke was gonna happen every minute." So, there are a lot of elements that are going on in those first two weeks that really require a specialist to say, "This is normal. This requires more attention," and to really help people get through a lot of the changes that come with stroke and brain injury.
Dr Grouse: Now, your article gave a really great, I think, example, where you had a juxtaposition of a hypothetical patient with a stroke and two very different post-discharge courses, one where they really kind of fell into that vacuum, that post-discharge vacuum, where they didn't get support and had some very disappointing outcomes versus a patient who did have a transitional care program with a lot of support post-discharge, and a lot of obstacles were overcome and problems solved such that the patient could do a lot better. And I encourage our listeners to take a look at it. If you could design and run it, how would your ideal transitional post-stroke program be structured? Like, how would you design it so that it would optimally support these patients?
Dr Bahouth: Yeah, you know, we, um, tangle with this every day in our current transitional stroke program that we call the JSTEP program. We've had several chapters of what we think is ideal for a patient, and thank you for sort of acknowledging that, like, the way those cases were written were really to underscore that we can have a lot of influence for patients. And while they were sort of hypothetical juxtapositions of one another, these are things we literally see every single day for our stroke patients. And people say, "Oh, if only we had done this, we would've caught that, and we would've prevented such-and-so." Some of the indicators of success have been we've really reduced our readmission rates to the hospital. We have decreased our length of stay because the confidence people feel to go home because they're well supported. So there have been indicators of success. But if I could take our program even next level, I would probably include a few other things. So currently, some of the strengths of the program are that a stroke specialist sees a patient within days of their discharge from the hospital, a time where some of those questions are sort of raising for the patient. Maybe a complication is starting to pop up that we can address before it, uh, gets out of hand and requires a readmission. We can tackle some of the fears that patients are having to say, "I wonder if this is normal or not. I better just go to the hospital." So, some of that early touch point by a true stroke specialist is really critical. And that visit only happens because the seed is planted in the hospital, so there really has to be some initiation of the program at the time the patient is in the hospital to say, "This is what you can expect when you leave here. You have someone who's walking this with you. They're a stroke specialist. They're gonna know how to help you navigate." The second part of our program that is a success is our rapid connection to specialties. So, we know that stroke patients are gonna need connection to rehabilitation specialists, physiatrists, the therapists. We know they're gonna need connection to cardiology when atrial fibrillation or heart failure or something is really at an extreme.We know endocrinology might be a part of the patient's story going forward. And so, I think the second success of our program is really alliance with key stakeholders in a stroke patient's life and quick access to having the patient be connected to what it is they need in the moment that we realize that there is a situation at home. The third thing that I think has been really a success of our program is this interprofessional education that we schedule patients for at the time of their discharge, just as any other important healthcare visit. During this interprofessional education session, the patients get to meet dietician, pharmacist, nurse, therapist, where key discussions about healthy behaviors, avoidance of complications after stroke really happen in a group session where there can be a lot of interaction. You know, currently our education happens in a time where the brain is injured, the patient is not sleeping well in the hospital. We have a lot of stress and fear. It's not the perfect time for anyone to receive such important education. So, I think the third really most important thing has been this formalized interprofessional education to really bolster the education that started at the hospital. If I were to really take our program next level, and every day we're considering it, I really think we haven't done a couple of key things. One is we have not really found a way for the care partner to be supported, that the care partner is usually the brave one sitting there with a tight lip and nodding and very, you know, concerned about what's happening and taking close notes. But we really haven't done well to just manage the care partner's needs sort of independently of the patient themselves, sort of help them with the experience of going through this. I think that could benefit both the care partner and the patient by sort of bolstering their sort of emotional consequences of this. And they are really our key partner in the patient's success in the outpatient setting, getting the patient motivated, helping them get to appointments, helping them to adhere with medications. So, I think if we can focus a bit more on the care partner, that might really bolster the long-term effect for patients. And I think finally, behavior change is very complex. Sometimes we're taking a group of patients who may have never exercised and said, "You know, we really... You need to walk several minutes a day. You need to increase your aerobic capacity. We need you to stop smoking." And these are not behavior changes that can just happen with sort of a one-time visit. So, I think we really need to incorporate a lot more of exercise therapy and concepts of people who can sort of coach along the continuum for some of these behavior changes so that we can really promote wellness and a return to health. And I think one final thing that could be additive from a transitional stroke program is really a better way to truly measure recovery for stroke patients, some of those in between the line measures that we're not really getting by a three-month modified Rankin score. I think a transitional stroke care model would really allow us to both insert research and potential other therapies along this time period, but also measure the success of those in a more granular way.
Dr Grouse: Thank you so much for that, and also it was really helpful to get a good overview of, like, what the transitional care program really means, right? Like, what is the structure? What is happening with the patient? So, I think all of that's really helpful. But I can't help but think, listening to all of that, that sounds like while certainly in an ideal state, and I don't think anyone can argue with how helpful that sounds, is it always something that's practical? Can we implement things like this, especially where access is limited, resources are dwindling as far as what patients can get and what evaluations patients can get? Do you think that this is something that can actually be implemented in programs throughout the country? And what are strategies we can consider to try to improve getting some of these resources for our patients?
Dr Bahouth: I think this is such a critical topic. I think that we have, in the medical system, tried to force our healthcare practices into old models of care instead of sort of adopting new ones. And so, I think that, you know, while everyone says, "Wow, that sounds like a very resource-rich program," I would have to stop and push back and say, well, a very resource-rich situation is when a stroke patient, sometimes fifteen to twenty percent of the time, are readmitted to the hospital at a time where hospital beds are at a premium. Maybe we need to turn those dollars of savings of sort of these readmissions and extra length of stay into dollars that we put into sort of this transitional period where we help promote success. So, I think it really becomes more of a value proposition when you talk about it. But that said, of course, we have to make sure that we're a high-value, high-productivity system. So, our current transitional care program uses a telemedicine structure. We know that stroke patients cannot drive in most states after their stroke. We know that their care partners are trying to return to work and normalize. It is very difficult for patients with paralysis, cognitive changes to come back and forth to multiple appointments. In the past, we have tried to make this transitional care program an in-hospital program. I think using the technologies that we have available for telemedicine are critical, especially for this population who have barriers to getting to their appointments. So, I think with a very low resource investment, a transitional care program can be created once you really develop the skills of the, the stroke team to really reach beyond the hospital with the tools that we already have in the hospital and just extend that to the next chapter. It is an investment, most certainly, but I think it's one well worth the investment for the patient's success, their quality of life, as well as some of the value metrics that we judge our hospitals by.
Dr Grouse: Are some of the transitional care codes that CMS has put out in recent years helpful to get some reimbursement for these types of visits?
Dr Bahouth: Absolutely. So, I think that's been a really wonderful policy change that has happened, recognizing the importance of these transitional care models. There are billing codes that allow you to have higher billing than a usual neurology appointment when a patient is within a certain window, meeting certain criteria for their eligibility for such a visit.There are codes that have now been developed and are being more and more utilized to have visits with care partners and realize that the care partner is an important member of the equation of this patient's success. So, there are definitely codes that can be used. I think we're very good in healthcare of delivering a lot of free care, but that's not the nature of the beast these days. We have to really be very aware of our dollars and cents, and so utilizing some of these important codes that I hope only continue to expand to recognize the importance of the transitional period for patients.
Dr Grouse: Now, Mona, I wanted to ask, was there anything that you wish you could have included in this article that didn't make it in?
Dr Bahouth: You know, obviously, um, word limitations are always challenging. I think that the article, I think, does a good job going sort of from beginning to end. I think a deeper section, certainly we have commented on the sort of sociodemographic challenges of a program like this that also relies on a technology like telemedicine in many cases. But there are so many nuances to that conversation that I think that section could have definitely gone on for a much longer period of time to talk about some of the strategies, the strategic ways that we work hard to make sure that these type of transitional care programs are accessible to all, especially the vulnerable who may have challenges with accessing technology. But I will say it is possible. You know, we are in a urban city. We see a lot of patients with various insurance status and access to technologies, and we've had a very high show rate in our post-hospital transitional program, so it can be done with a thought and, uh, care to those vulnerable populations who may need more attention across the transition.
Dr Grouse: Well, I really appreciate all the work you've done in this area, and it sounds like it's an area that will continue to grow as we learn more and hopefully improve. And I really appreciate you taking the time out of your day to talk with us about your article.
Dr Bahouth: Well, thank you for having me, and it's a topic that's near and dear to us, so thanks again for highlighting its importance.
Dr Grouse: Again, today I've been interviewing Dr. Mona Bahouth about her article on transitional stroke care and the road to recovery. This article appears in the June 2026 Continuum issue on cerebrovascular disease. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today.
Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.
