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care coordination, continuity of care, discharge planning, follow-up after discharge, stroke, transitional care



  1. Puhr, M. Irene
  2. Thompson, Hilaire J.


ABSTRACT: Background: Transitional care (TC) models are used to reduce adverse outcomes and hospital readmissions. This article reviews the scholarly literature to identify TC models that have been used successfully in patients with stroke. Methods: Literature in CINAHL, PubMed, and the Cochrane Database of Systematic Reviews from January 2000 to June 2013 was searched using the keywords "transitional care," "discharge planning," "care-coordination," "continuity of care," "follow-up after discharge," and "stroke." Web sites of established TC models were also reviewed to identify additional studies meeting review criteria. To be included in the review, studies must have been written in the English language and focused on adult patients aged 19 years and older with stroke, discharged from the hospital or acute rehabilitation facility to home. TC interventions were defined as those that employed one or more of the National Transitions of Care Coalition intervention categories: medication management, transition planning, patient and family engagement or education, information transfer, follow-up care, healthcare provider engagement, or shared accountability across providers and organizations (National Transitions of Care Coalition, 2011). The author examined the title and abstract of each study for eligibility against stated criteria. Results: Thirteen articles representing 11 studies were found to meet the inclusion criteria. In the identified studies, TC was compared with usual care; however, what constituted usual care was not consistently elucidated. Fewer than half of the studies reported significantly improved results on selected outcomes. Across all the studies, TC did not result in a reported significant decrease in emergency department visits or hospital readmission rates. There was substantive heterogeneity in (a) intervention providers, (b) interventions used in TC, and (c) measures of outcome identified. Six of the 13 studies were identified as having successful interventions. Conclusion: Some evidence exists to support positive outcomes using TC in patients with stroke. Standardization of interventions and outcome measures is needed to determine the most effective interventions. Additional large-scale randomized, controlled trials should be undertaken to provide reliable data regarding effective TC interventions for persons after stroke.