Need for improved care transitions in case of stroke

Following the stroke onset, there is a need for hospitalisation with subsequent rehabilitation that includes a care transition from one care provider to another. Care transitions may impose the risk of adverse events and rehospitalisation due to lack of help to navigate the healthcare system. Uncoordinated transition can result in potential burden for patients and their significant others with a risk of information loss, no or delayed follow-up and rehabilitation and unwanted health outcomes.

To be able to understand the care transition from the perspectives of the involved stakeholders, researchers at NVS have explored care transitions from the hospital to continued rehabilitation in the home for people with stroke and their significant others. Individual interviews and focus groups have been conducted with patients, significant others and healthcare professionals from hospital and multidisciplinary neurorehabilitation teams in primary care.

The study recently published in the "International Journal for Integrated Care" showed that the care transition involved several parallel processes that needed to be synthesized and coordinated for professionals to make holistic decisions based on the individual's needs. All involved actors, both within organizations and between organizations, need to coordinate their actions to provide well-functioning care transitions. A prerequisite for succeeding in creating a well-functioning care transition was the need for dialogue within and between providers to gain a shared understanding of the care trajectory, and how the own part of the process relates to and affects other parts.

Patients and significant others described the care transition as a sudden transformation from a passive attendant at the hospital with lack of involvement and dialogue about their care and rehabilitation to suddenly being discharged to the home without support and preparation and being solely responsible for managing their health. The lack of participation in their care led to concerns and lack of control over their situation. There was a great need for improved dialogue between patients and healthcare professionals regarding the current state of health, processes and procedures within the healthcare system and support in self-management after discharge.

Need for dialogue and coordination (Responsible researchers' comments):

“We, in the healthcare sector, must increase our dialogue with other caregivers and patients, i.e. involve each other and communicate based on a common understanding. The study shows that dialogue is the key to creating successful care transitions that are tailored to the needs of the individual. This applies both to dialogue between professionals and patients to develop an understanding of the individual's unique needs, but also that care providers and healthcare professionals within and between organizational boundaries need to communicate to create an understanding of each other to avoid faults and misunderstandings. This is easier said than done in a system that usually not enables and promotes communication and coordination of efforts between healthcare providers. Several parts of the system are required to make changes to achieve a safer transition for the patient".

Based on the results of the study, work is now underway to develop improved care transitions. This is done in a co-design process where patients, significant other and healthcare professionals jointly design and develop a new type of care transition.