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

Maureen Markle-Reid, Ruta Valaitis, Amy Bartholomew, Kathryn Fisher, Rebecca Fleck, Jenny Ploeg, Jennifer Salerno, Maureen Markle-Reid, Ruta Valaitis, Amy Bartholomew, Kathryn Fisher, Rebecca Fleck, Jenny Ploeg, Jennifer Salerno

Abstract

Background: Stroke is the leading cause of death and adult disability in Canada. Eighty percent of older adults (≥65 years) who have suffered a stroke will return to their homes, and 60% will require ongoing rehabilitation. The transition between hospital and home is often fragmented, leading to adverse health outcomes, hospital readmissions, and increased health-care costs. This study examined the feasibility of a 6-month integrated transitional care stroke intervention (TCSI), and explored its effects on health outcomes, patient and provider experience, and cost in 30 community-living older adults (≥55 years) with stroke and multimorbidity (≥2 chronic conditions) using outpatient stroke rehabilitation services.

Methods: The TCSI is a 6-month intervention delivered by an interprofessional (IP) team (occupational therapist, physiotherapist, speech language pathologist, registered nurse, social worker). It involved care coordination, home visiting, and IP case conferences, supported by a web-based application. A qualitative descriptive approach was used to explore the feasibility of implementing the intervention. A prospective one-group pretest/posttest was used to evaluate the effects of the intervention on health outcomes and use and costs of health services, from baseline to 6 months.

Results: Participants had an average of eight comorbid conditions. The intervention was feasible and acceptable to both older adults and providers. From baseline to 6 months, there was no statistically significant difference in health outcomes. However, there was a significant reduction in the total per person use and costs of health services.

Conclusions: This study established the feasibility of conducting a larger randomized controlled trial of this intervention.

Keywords: Older adults; community living; integrated care; mobile apps; stroke rehabilitation; transitional care.

Conflict of interest statement

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

© The Author(s) 2020.

Figures

Figure 1.
Figure 1.
TC intervention activities. TC: transitional care.
Figure 2.
Figure 2.
Study flow of participants.
Figure 3.
Figure 3.
Interpreting 95% CIs for PCS and MCS (n = 25). CI: confidence interval; PCS: physical component summary score; MCS: mental component summary score.

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