Person-centred care transitions for people with stroke: study protocol for a feasibility evaluation of codesigned care transition support

Abstract

BackgroundCare transitions following stroke should be bridged with collaboration between hospital staff and home rehabilitation teams since well-coordinated transitions can reduce death and disability following a stroke. However, health services are delivered within organisational structures, rather than being based on patients’ needs. The aim of this study protocol is to assess the feasibility, operationalised here as fidelity and acceptability, of a codesigned care transition support for people with stroke.MethodsThis study protocol describes the evaluation of a feasibility study using a non-randomised controlled design. The codesigned care transition support includes patient information using videos, leaflets and teach back; what-matters-to me dialogue; a coordinated rehabilitation plan; bridged e-meeting; and a message system for cross-organisational collaboration. Patients with stroke, first time or recurrent, who are to be discharged home from hospital and referred to a rehabilitation team in primary healthcare for continued rehabilitation in the home will be included. One week after stroke, data will be collected on the primary outcome, namely satisfaction with the care transition support, and on the secondary outcome, namely health literacy and medication adherence. Data on use of healthcare will be obtained from a register of healthcare contacts. The outcomes of patients and significant others will be compared with matched controls from other geriatric stroke and acute stroke units, and with matched historic controls from a previous dataset at the intervention and control units. Data on acceptability and fidelity will be assessed through interviews and observations at the intervention units.Ethics and disseminationEthical approvals have been obtained from the Swedish Ethical Review Authority. The results will be published open-access in peer-reviewed journals. Dissemination also includes presentation at national and international conferences.DiscussionThe care transition support addresses a poorly functioning part of care trajectories in current healthcare. The development of this codesigned care transition support has involved people with stroke, significant other, and healthcare professionals. Such involvement has the potential to better identify and reconceptualise problems, and incorporate user experiences.Trial registration numberhttp://www.clinicaltrials.gov id: NCT02925871. Date of registration 6 October 2016.Protocol version1.

The Use of Teach Back at Hospital Discharge to Support Self-Management of Prescribed Medication for Secondary Prevention after Stroke—Findings from A Feasibility Study

“…The study was carried out in the context of a feasibility study of a codesigned care transition support for people with stroke [26]. The care transition support was a multicomponent intervention.…”

Care Transitions for People with Acquired Neurological Disability in the First 12 Months following Inpatient Rehabilitation: Health Service Use and Obstacles

“…Person-centred care approaches, tailoring treatment to individual needs and providing personalized monitoring of developing issues and changing goals, are well established as central to efective rehabilitation and are already employed by many rehabilitation services. Approaches which support more comprehensive "personalised rehabilitation pathways" to enhance care transitions include utilisation of case management [67][68][69], care navigators [70,71], integrated care models [72,73], self-management approaches [74,75], improved resourcing [67,70], improved communication including (patient controlled) EMR [71,76], and person and family-engaged approaches [77,78]. Further studies are needed to examine the best strategies or models for implementing more personalised rehabilitation pathways for people with SCI and ABI.…”

A person-centred care transition support for people with stroke/TIA: A study protocol for effect and process evaluation using a non-randomised controlled design

“…Hence, the intervention has been developed by identifying the evidence base for the care transition literature [23][24][25][26], understanding local needs and context through our prestudies [7,8,27], and by conducting a co-design process [28] with patients, significant others, and healthcare professionals. The intervention has been tested in a feasibility study investigating fidelity, acceptability, and implementation aspects [29,30]. Preliminary results show that the intervention is feasible from the perspective of healthcare professionals and patients, and that the proposed methods for evaluation are suitable for patients who recently had a stroke, as well as for their significant others [30].…”