Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol

Abstract

BackgroundFor some stroke patients and caregivers, navigating the transition between hospital discharge and returning home is associated with substantial psychosocial and health-related challenges. Currently, no evidence-based standard of care exists that addresses the concerns of stroke patients and caregivers during the transition period. Objectives of the Michigan Stroke Transitions Trial (MISTT) are to test the impact of a social worker home-based case management program, as well as an online information and support resource, on patient and caregiver outcomes after returning home.MethodsThe Michigan Stroke Transitions Trial is a randomized, pragmatic, open (un-blinded), 3-group parallel designed superiority trial conducted in 3 Michigan hospitals. Eligible participants are adult acute stroke patients discharged home directly or within 4 weeks of being discharged to a rehabilitation facility. The patient’s primary caregiver is also invited to participate. Patients are randomized on the day they return home using a randomized block design. Consented patients discharged to a rehabilitation facility who do not go home within 4 weeks are dropped from the study.The 2 study interventions begin within a week of returning home and conclude 3 months later. The 3-group design compares usual care to either a home-based social worker stroke case management (SWSCM) program, or a combination of the SWSCM program plus access to an online information and support resource (MISTT website). Outcomes data are collected at 7-days and 90-days by trained telephone interviewers. Primary patient outcomes include the PROMIS global 10 score (a generic Quality of Life scale), and the Patient Activation Measure (PAM). Caregiver outcomes include the Bakas Caregiving Outcomes Scale. Final analysis will be based on 214 randomized acute stroke patients. To accommodate subjects excluded due to prolonged rehabilitation stays, as well as those lost-to-follow-up, up to 315 patients will be consented.DiscussionThe MISTT study will determine if a home-based case management program designed around the needs and preferences of stroke patients and caregivers, alone or in combination with a patient-centered online information and support resource can improve stroke survivor and caregiver outcomes 3 months after returning home.Trial registrationClinicalTrials.gov: NCT02653170 (Protocol ID: 135457). Registered April 9, 2015.

Social work support and unmet social needs in life after stroke: a cross-sectional exploratory study

“…In the MAS-I study 24% of the caregivers reported moderate to high levels of stroke-related caregiver burden [11]. Several approaches have been suggested to close the gap between inpatient and outpatient care [52][53][54], however, social care has been understudied. An effective primary care-based stroke aftercare service must have a broad focus and must be based on an individual record of unmet needs including social needs [55].…”

Development of an informational support questionnaire of transitional care for aged patients with chronic disease

“…[14][15][16] These patients, who are repeatedly transferred from hospitals to their homes often do not get high-quality information support; resulting Open access in a poor quality of continuing care, especially in medication information and discharge plan implementation. [17][18][19][20] Therefore, for this special vulnerable group, we need to ensure high-intensity information support in carrying out their transitional care. 21 22 This is cost-effective for the country, both in terms of economy and social benefits.…”

An integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A feasibility study

“…Although TC interventions for older adults have been linked to several positive outcomes, including lower hospital readmissions, the effectiveness of these interventions for older adults with stroke and multimorbidity is uncertain. 9,18 Current Canadian best practice guidelines for managing care transitions following stroke are largely built upon evidence from observational or qualitative studies, or expert consensus. 13 The majority have focused on hospital-based, post-acute care (<3 months) initiatives, including early supported discharge interventions, [19][20][21] while few have examined the role of outpatient or other community-based teams in supporting care transitions beyond the post-acute period.…”