Navigating the healthcare system after a stroke can be overwhelming for individuals and their loved ones. Many stroke survivors have no prior experience with similar situations and do not know how to ensure their best chances for recovery. With a variety of treatment options, specialists, and support services, it can be challenging for patients and their families to identify and access the right care. Medical jargon, complex treatment plans, and emotional stress add to the confusion.
In 2024, the Centers for Medicare & Medicaid Services (CMS) introduced coding and coverage for Principal Illness Navigation (PIN) services. The CMS coverage of PIN services was developed based on decades of work in cancer navigation.1 This work has shown that navigation services can help reduce health disparities and improve patient outcomes. It has also established standards for the ethics, qualifications, knowledge, skills, activities, and supervision of navigators.1
Principal Illness Navigation services can be billed to health insurance for serious conditions, like stroke, that cause an increased risk of hospitalization, nursing home admission, or death. The goal is to provide survivors with holistic support and access to timely and coordinated care as they go through their journey towards recovery. Services included under PIN that can help survivors with the recovery process include:
- Person-Centered Assessment
- Supportive Services
- Care Coordination
- Health Education
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- Building Patient Self-Advocacy Skills
- Healthcare System Navigation
- Facilitating Behavior Change
- Support, Mentorship, or Inspiration
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What are the benefits of Principal Illness Navigation (PIN) Services?
The first year after a stroke is a critical period for a stroke survivor's recovery, with both opportunities and risks. With the support of rehab specialists, stroke survivors can often use their neuroplasticity to recover meaningful function. However, also during this period, approximately 50% of stroke patients are readmitted to the hospital.1 Impairments caused by the stroke make survivors more susceptible to issues like infections and falls. Moreover, managing the discharge plan and recovery process can pose a significant challenge
Supporting stroke survivors involves addressing a diverse range of needs. Survivor's needs can include addressing the medical conditions that may have led to the stroke, managing any additional health issues the survivor may have, coordinating treatment, recovering from and adapting to post-stroke impairments, and navigating benefits and resources to address the social determinants of health (SDOH) disparities that can serve as barriers to recovery.
To address these challenges, PIN services offered by Kandu prioritize health education, care coordination, follow-up, social support, emergency planning , and self-advocacy. By taking advantage of these services, stroke survivors may improve their outcomes and reduce the likelihood of costly hospital readmissions. Participants in Kandu’s program to-date have experienced hospital readmissions at half the rates seen in published literature.2
How can I find Principal Illness Navigation (PIN) services for a Stroke Survivor?
Kandu is an organization that provides PIN services to stroke survivors. We offer personalized assistance to survivors and their care partners, starting with utilizing the survivor’s discharge plan from the hospital and identifying and resolving any obstacles that may prevent patients from reaching their recovery goals. Kandu achieves this through clinical care, care coordination, and advocacy.
Once the survivor is back in a community setting and enrolled in the Kandu program, they have access to a Kandu Navigator, a community of other survivors and care partners, and an app with personalized education, resources, and tools. We work to get them on a supportive path to recovery as early as possible. Kandu also maintains ongoing communication with the stroke team at the hospital and can communicate concerns and support care coordination between inpatient and outpatient settings when needed.
PIN Services and Kandu Paves the Way to Optimal Stroke Recovery
Stroke recovery can be a challenging and lonely journey, and many survivors require support along the way. With PIN services like those offered by Kandu, survivors can receive help to overcome many of the barriers to achieving their best possible recovery outcomes. Instead of finding their way on their own, they can seek and receive expert, timely advice from their designated Kandu Navigator who is just a text message or phone call away.
PIN increases stroke survivors' access to education, recovery resources, community, and clinical resources, providing them with the opportunity to maximize their recovery.
