The Use of Transitional Care Models in Patients With Stroke.

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The Use of Transitional Care Models in Patients With Stroke M. Irene Puhr, Hilaire J. Thompson

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

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atients with stroke experience an acute assault to their health, lifestyle, and ability to function in their societal roles. Upon discharge from the hospital, they face a chronic medical condition with rehabilitation goals, multiple new medications, altered diets, and for many, lasting physical deficits. At a point in time when patients could most benefit from an intensified program of care, they may be discharged directly from the hospital to home and be expected to reintegrate these many changes into their daily routines. The move from the inpatient setting to the outpatient setting changes the locus of care from the interdisciplinary hospital team

Questions or comments about this article may be directed to M. Irene Puhr, DNP ARNP, at [email protected]. She is an AdultGerontology Nurse Practitioner, Whidbey Island Internal Medicine, Coupeville, WA. Hilaire J. Thompson, PhD RN CNRN ACNP-BC FAAN, is an Associate Professor of Behavioral Nursing and Health Systems, University of Washington, Seattle, WA. The authors declare no conflicts of interest. Copyright B 2015 American Association of Neuroscience Nurses DOI: 10.1097/JNN.0000000000000143

to the primary care provider (PCP) and, frequently, a host of rehabilitative professionals. To work effectively, this transition of care depends on the collaboration of the parties involved to coordinate healthcare and support services while engaging patients with stroke and their caregivers as active participants in care. Traditionally, the transitional care period has not been an ideal model of collaboration. Collaboration is a process whereby individuals and organizations cooperate to work together toward a joint goal. Baggs and Schmitt (1988) describe the following as attributes of collaboration: planning together, making decisions, solving problems, setting goals, assuming responsibility, working together cooperatively, communicating, and coordinating openly. However, deficits in communication between hospitalists and PCPs, missing or inadequate discharge summaries, and missing test results appear to be the norm in many patient discharges from the hospital. Gaps in communication between nurses and patients, hospitalists and patients, and hospitalists and PCPs can result in negative health outcomes for patients. Naylor and Keating (2008)

Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

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identified some of these negative outcomes: frequent medication errors, follow-up appointments and tests that are either not scheduled or missed, and home care services that are not accessed. Patient and caregiver education in the acute care setting may not adequately prepare patients and family caregivers to identify symptoms requiring early intervention and thus prevention of rehospitalization. In addition, patients may arrive at follow-up appointments to find providers unaware of their hospitalizations or missing test results and other important information (Moore, Wisnivesky, Williams, & McGinn, 2003). A study by the Mayo Clinic revealed that fewer than half of discharged patients could list their medications or identify their diagnoses, making adherence to medication and lifestyle changes questionable (Makaryus & Friedman, 2005). Finally, patients, caregivers, and providers all report frustration and dissatisfaction with the transition process (Kripalani et al., 2007). Transitional care typically refers to the healthcare received as patients move from one healthcare setting to another (Enderlin et al., 2013). Transitional care models have been developed to deal with existing poor quality of care and high healthcare costs. They provide a framework on which to base patient-centered care, reduce hospital readmissions, and decrease healthcare costs. Naylor’s Transitional Care Model, Coleman’s Care Transitions Intervention, Project Re-Engineered Discharge, Better Outcomes by Optimizing Safe Transitions (Project BOOST), Johns Hopkins’ Guided Care, and the Centers for Medicare and Medicaid Services’ Community-based Care Transitions Program are all examples of evidenced-based transitional care models (Peikes, Lester, Gilman, & Brown, 2013; Robert Wood Johnson Foundation, 2013). Although patients with stroke have been included in studies evaluating these transitional care models, none of the studies supporting these models were conducted using exclusively patients with stroke. Transitional care models are composed of certain interventions felt to contribute to successful patient outcomes. The National Transitions of Care Coalition (NTOCC) has described seven essential intervention categories: medication management, transition planning, patient and family engagement/education, information transfer, follow-up care, healthcare provider engagement, and shared accountability across providers and organizations (NTOCC, 2011). Not all of the transitional care models identified above utilize all of the seven interventions described. The goal of this article is to review the scholarly literature to identify transitional care models that have been used successfully in patients with stroke. The studies identified in this literature review did not use an established transitional care model such as Care Transitions

Transitional care models include select interventions that likely contribute to successful patient outcomes; although patients with stroke have been included in some studies evaluating a number of these models, none of the previous research exclusively studied patients with stroke. Intervention, Naylor’s Transitional Care Model, or Project BOOST. They did, however, use a model of their own devising that employed one or more of the NTOCC intervention categories and thus will be evaluated as transitional care models in their own right.

Methods Literature in CINAHL, PubMed, and the Cochrane Database of Systematic Reviews was searched using the keywords ‘‘transitional care,’’ ‘‘discharge planning,’’ ‘‘care-coordination,’’ ‘‘continuity of care,’’ ‘‘follow-up after discharge,’’ and ‘‘stroke.’’ Filters were then placed limiting studies to those with abstracts written in English and published from January 2000 to December 2013 and conducted with human subjects aged 19 years and older. Studies were limited to articles written in English and published from January 2000 to December 2013, focused on adult populations aged 19 years and older. The studies were required to evaluate the results of transitional care interventions used exclusively with patients after stroke. For the purposes of this review, successful use of a transitional care model is defined as resulting in one or more of the following: (a) a reduction in emergency department (ED) use or hospital readmission rates, (b) a reduction in the incidence of re-stroke, (c) reduction in rate of depression, (d) improvement in stroke knowledge, (e) improvement in quality of life (QOL), (f) improvement in neuromotor function, or (g) improvements in The Joint Commission (2009) Stroke Core Measures.

Results The initial search yielded 1339 abstracts for initial review. Applying the filters described above reduced the number of abstracts for review to 199. After reviewing full title and abstract of the 199 articles, only 15 were found to initially meet the inclusion and exclusion criteria. The full text of those 15 articles was then reviewed against inclusion and exclusion criteria. On the basis of


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full-text review, two additional articles were eliminated leaving 13 articles in the final review. In two instances, the data from one study were analyzed for multiple articles; thus, these 13 articles identified in the review represent 11 unique projects. Most studies were randomized controlled trials, and one preintervention and postintervention study was found in the search. Three of the studies were conducted in Norway; three were conducted in the United States; two were conducted in Canada; and one each was conducted in Australia, Germany, and the United Kingdom. The studies evaluated the transitions from the hospital or inpatient rehabilitation to home. In 8 of the 11 studies, patients were cared for in comprehensive stroke units while in the hospital. In one study, patients were cared for on a general medical ward, and another study included patients from a mix of settings including a stroke unit, a rehabilitation unit, and a general medical ward. Specialized stroke units have been shown to provide superior outcomes compared with general medical wards (Stroke Unit Trialists’ Collaboration, 2007); thus, the setting of the intervention is important to understand when critiquing the available literature. One of the studies did not identify the site used to obtain the sample (see Table 1).

Transitional Care Interventions The interventions used in the different studies varied considerably. All studies examined used more than one intervention with discharge planning being common to all. Other interventions included education regarding stroke and secondary prevention, emotional support for both patients and caregivers, ongoing rehabilitation/ physical therapy, engaging the PCP through information sharing and education, medication reconciliation, early discharge, and connecting the patient with communitybased services (see Table 1). Some interventions were conducted by telephone, some were conducted during home visits, and some were conducted with a combination of the two. The actual number of visits or telephone calls varied among studies and at times within the studies (Table 1). The frequency of intervention was usually determined on an as-needed basis, and the actual number of interventions was not always provided in the description of the study. In addition, diverse interventions were provided to individual subjects within specific studies (Table 1). Protocols were not always used to guide the facilitators, resulting in heterogeneous strategies being used as interventions. Interventions provided to the control groups were not always clearly delineated. Most provided the ‘‘usual in-hospital care’’ for the individual setting described, yet the usual care was not specified in each study. A discharge summary for the PCP was commonly

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provided. The control groups then received care as directed by the PCP.

Intervention Provider The facilitators of the interventions included social workers, nurses, advanced practice nurses, physical therapists, occupational therapists, medical doctors, family support organizers, study coordinators, professional carers, and multidisciplinary teams (Table 1). Some of the less well-known types of facilitators, such as the family support organizers and ‘‘professional carers,’’ received special training in caring for patients with stroke. The training was neither specified nor standardized across studies.

Outcome Measures and Measurement As shown in Table 2, over 30 different commonly accepted measures of outcome were used to evaluate the interventions. Neuromotor function was assessed with the Timed Up and Go test, the National Institute of Health Stroke Scale, the Scandinavian Stroke Scale, or the physical component of the 36-item Short Form Health Survey, to name a few. Independence in activities of daily living was gauged by the Barthel Index, the Functional Independence Measure, the 30-item Stroke Adapted Sickness Impact Profile, or the modified Rankin Scale. The Center for Epidemiology Studies Depression Scale, the Geriatric Depression Scale, the MontgomeryYAshberg Depression Scale, and the Zerssen Depression Scale were all used to identify mood and depressive disorders. This list is not exhaustive. Questionnaires specifically designed by researchers to measure health risk management (e.g., blood pressure, lipids, falls, or medication adherence) were also utilized. In Table 2, the individual measures of physical data are grouped under health risk management in keeping with most of the studies. Wide-ranging periods of time were chosen to evaluate the various outcomes in the studies included in this review (Table 2). Depending on the specific study, outcomes were measured at one or more of the following times: 1, 3, 4, 6, 9, or 12 months. Baseline measurements were obtained in most studies. Across the board, the degree of positive benefit from the various interventions was rarely significant (Table 2). Each study used multiple outcome measures, and only 2 of 11 studies reported statistical significance in each of the outcomes measured. More commonly, significant differences occurred in only 1 or 2 of the up to 16 outcomes measured in each individual study. Positive benefit was seen in neuromotor function in 4 of the 11 studies. Significant outcomes in QOL, depression and mood, and adherence were reported in two studies apiece. Patient satisfaction with the intervention, risk factor reduction, patient knowledge regarding


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46 control, 47 study


Allen et al., 2002; RCT

Askim et al., 2004; RCT

Nurse, interdisciplinary team (OT and PT, mobile stroke team) and primary healthcare system

Early supported DC, home-based rehabilitation program, mobile stroke team goes to home

APN, interdisciplinary Individualized team, PCP care plans, DC planning, DC summary to PCP, baseline assessment by APN, practice guidelines, care plan to PCP

Individualized 190 control, APN; PCP; 190 study interdisciplinary team: care plans, DC planning, OT, PT, ST, SW medication reconciliation, DC summary to PCP, baseline assessment by APN, practice guidelines, care plan to PCP


No significant differences in outcome. Disability: Mod. Rankin, BI; subjective health: Nottingham Health Profile (NHP); Caregiver Strain Index (CSI) ASAP, then within 4 weeks; pt. evaluated at 6, 26, and 52 weeks

Inpt stroke unit and rehabilitation

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Intervention group clearly superior, p G .0001 Neuro Fxn: NIHSS, BI; depression: CES-D; 30-item Stroke Adapted Sickness Impact Profile; management of health risks; stroke knowledge Home visit by 1 month, telephone calls 3Y7 days post-DC, total intervention = 3 months

Care by PCP, no DC In-home visit by care plan, 3-month APN, telephone evaluation calls by APN, evidence-based protocols, APN worked collaboratively with PCP, used guidelines, care plan to PCP, letter with plan of care to pt. In-home visit by PCP 2; pre-DC family, doctor, stroke team meeting; telephone calls by mobile team; local support group meetings

Before DC, pt. had SW and PT arranged and PCP received DC summary. Use of stroke unit with enhanced DC planning left little room for outcome improvement. Neuro Fxn: NIHSS, Timed Up and Go quality of life: SSQOL; time in nursing home or death; questionnaire to test stroke/health knowledge; risk management: BP, cholesterol, depression, meds

In-home visit by APN, telephone calls by APN, extra telephone calls as needed by APN, APN attended PCP visits, stroke ed. and personal health record, PT, home visits by APN

Begun at 1 week: weekly 4, monthly 5 and APN; total intervention = 6 months

PCP received pt. summary, med reconciliation, DC plans and APN initial assessment

Comments

Intensity/Duration

Methods Used

Outcome Measures

Intervention Type Control/Usual Care

Allen et al., 2009; RCT

Facilitator

Summary Table of Literature Review Findings Regarding Transitional Care Model Components

Author, Date; Design Sample Size

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Social workers (MSW)

Same as above

Claiborne, 2006a; randomized precomparison and postcomparison

Nurse, mobile stroke team (OT, PT, MD), primary healthcare system

Social workers (MSW)


Claiborne, 2006b; randomized precomparison and postcomparison

Pre-DC family meeting with mobile team, home visit with mobile team and PC health system, home-based rehabilitation program, pt. ed.

Same as above

In-home visit by MSW, telephone calls by MSW, ed. and support services

F/U treatment as determined by PCP

Same as above

Same as above

Methods Used

Same as above

Inpt stroke unit and Early supported DC, home-based Inpt rehabilitation rehabilitation program, mobile stroke team home visits, report to PCP with care suggestions

Same as above

Assess QOL, health status, mental health, service needs, and entitlements; coordinate services; educate caregivers; monitor pt. progress

Same as above; early, intensive task-specific therapy

Intervention Type Control/Usual Care

Extended stroke unit service outcomes better than ordinary stroke unit service Measured at 6 and 26 weeks; independence: mRS and BI; % institutionalized; length of stay in institutions Meeting ASAP, F/U mobile team 1 month, group meeting at 3 months

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Self-report data not highly accurate. Did not know charges, used a mean amount. $1000 savings per pt. Number of visits reported by pt. to medical professional used to calculate data. Inpt visits used actual reimbursement data.

Significant improvement in depression and mental QOL. Also improved health risk management. Used a self-report survey to assess outcome. QOL, physical and mental: Short Form-36 (SF-36); depression: Geriatric Depression Scale (GDS); health risks management

Home visit at 1Y2 weeks, telephone calls weekly for 20Y60 minutes, total intervention = 3 months

Same as above

No significant differences in outcome.

Comments

Berg Balance Scale, walking speed

Outcome Measures

Same as above

Intensity/Duration

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Indredavik, Fjaertoft, 160 control, 160 study Ekeburg, Loge, & Morch, 2000; RCT

Same as above


Askim et al., 2006; RCT

Facilitator

Sample Size

Summary Table of Literature Review Findings Regarding Transitional Care Model Components, Continued

Author, Date; Design

TABLE 1.

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Professional carers, male nurses qualified in neuro and rehabilitation, PT, nurses

Neurologist, PCP, study coordinator

29 control, Grasel, Biehler, Schmidt, & Schupp, 33 study 2005; controlled clinical trial

Joubert et al., 2006; 45 control, RCT 35 study

Facilitator

Nurse, mobile stroke team (OT, PT, MD), primary healthcare system

Sample Size

Social service assistance with forms, in-home care, etc.; self-help and support group referrals; caregivers watch therapy sessions and receive ed. regarding pt. care; applications for durable medical aids done; ‘‘care relocation report’’ to home health nursing service

Therapeutic weekend care; pt. and caregiver ed. regarding home care; ed. regarding caregiving burden, outpatient care services, support groups; telephone counseling

Pre-DC weekend at home with assist, nurses at bedside, group seminar

Home 1 weekend before DC, 3 45- to 60-minute classes, 1 before DC, clinic visit at 3 months

Same as above Same as above

Flow charts to Faxed information Shared care plan Received same Q 3 months; missed to PCP: risk factor 12-month evaluation record data, as study group references from appointments goals based on tracked and literature; practice guidelines. telephone call, rescheduled. Arranged F/U at Telephone calls screening for 2 weeks and 3, 6, 1 week before each QOL, 9, and 12 months; PCP visit and after depression telephone each appointment assessment to assess changes in care.

Same as above

Same as above


The ‘‘usual’’ transition care is so thorough it appears there is little room for improvement. Article does not supply information on who provided the various services. Better BP and lipid control, adherence to exercise at 3 months. 12 months: same as above. Much less depression in study group.

Assessed at 6 months; neuro fxn: BI, Fxn Independence Measure, Timed Up and Go, Ashworth Spastic Scale, Frenchay Arm Test; QOL: SF-36; caregiver stress: Zerssen Dep. Scale, burden scale for family; Giessen symptom list, self-assess Measured at 3 months: meds, BP, lab tests, carotid stenosis. Measured at 12 months: QOL, Aqol, CSI, social support survey; Frenchay aphasia test, MMSE, mRS, BI, London Handicap scale; access to community services

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Significant positive results for QOL only, trending toward significance on other outcomes.

Comments

Measured at 52 weeks; QOL: NHP; neuro fxn: Frenchay Activity Index; depresssion: MontgomeryYAshberg scale, MMSE; CSI

Intervention Type Control/Usual Care Methods Used Intensity/Duration Outcome Measures


Fjaertoft, Indredavik, Same as Johnsen, & Lydersen, Indredavik et al. (2000) 2004; RCT above


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168 control, FSO 168 study

Mayo et al., 2008

Tilling et al., 2005; RCT

FSO trained in PT, secondary prevention, health promotion, stroke knowledge, time management, emotional support, and special services and benefits system

Case management, hospital summary to PCP, arranged F/U with PCP

Measured at 3 months and 1 year: RNLI, hospital depression & anxiety scale, BI, CSI, and Pound Satisfaction Scale; major outcome: pt. satisfaction; emotional outcomes; utilization of healthcare services

Postal questionnaires or home visit used to evaluate significant increase in satisfaction with services and increased utilization of social services.

Study group had no difference in ed., hospital readmissions, or QOL.

6-week duration, Measured baseline, average of 4.8 home 6 weeks, 6 months: SF-36; RNLI, BI, TUG, visits GDS; utilization of healthcare services

Home visits, telephone calls, 24-hour contact

Instructed to make F/U appointment and given names if no PCP

Varied number Provide of contacts information regarding stroke, (range = 1Y60) secondary prevention, medications use, and entitlements. Provide ‘‘listening ear’’ and emotional support

Extremely detailed and descriptive. Study group superior physical health, QOL, RNLI, and IADL. Measured at 1, 2, and 3 months. Neuro fxn: SF-36, CNS, STREAM, TUG, BI, BADL, and OARS-IADL; disability: RNLI

4-week duration; home visit at least 1 time, then as needed. Varied among pts.

Individualized and coordinated by PT or nurse, home visits

Current practices at hospitals with acute stroke teams: PT, OT, and ST as ordered by PCP

Early DC, home rehabilitation

Assessments done by questionnaires mailed to home; positive increase in knowledge of stroke. No significant improvement in mood, ADLs, or decrease in caregiver strain.

Measured at 4 and 9 months. Mood: Gen. Health Quest (GHQ-12); neuro fxn: BI, Nottingham EADL; information regarding how to access comm. services; satisfaction with FSO; caregivers: CSI and GHQ-12

No records kept of interventions provided to control; no description of usual care

Pt. ed. regarding stroke, entitlements; assisted with DC planning and arrangements; provided support and information regarding resources

One visit each with pt. and carer; at least 1 time, then as needed. Varied among pts. Frequency unclear.

Comments

Inpt visit within 2 weeks, attended case conferences, liaison with rehabilitation team and caregivers, home visits made by FSO

Intervention Type Control/Usual Care Methods Used Intensity/Duration Outcome Measures

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Note. All transitions in care were from hospital to home. ADL = activities of daily living; APN = advanced practice nurse; BI = Barthel Index; BP = blood pressure; CES-D = Center for Epidemiological Studies Depression Scale; DC = discharge; ED = emergency department; ed. = education; FSO = family support organizer; F/U = follow-up; Fxn = function; Inpt = inpatient; MMSE = Mini-Mental Status Examination; NIHSS = National Institutes of Health Stroke Scale; OT = occupational therapy; PCP = primary care provider; PT = physical therapy; pt. = patient; pt. ed. = patient education; QOL = quality of life; RCT = randomized controlled trial; RNLI = Reintegration to Normal Living Index; SSQOL = Stroke Specific Quality of Life; ST = speech therapy; SW = social work.

Geriatric nurses

Multidisciplinary team: nurse, PT, OT, ST, and dietician


Mayo et al., 2000; RCT

Facilitator

FSO, multidisciplinary team referred to but not described

Sample Size


Lincoln, Francis, 124 control, Lilley, Sharma, 126 study & Summerfield, 2003; RCT


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TABLE 2. Study

Transitional Care Outcomes, Measurement, and Statistical Significance

Outcomes

Allen et al., 2009 Neuromotor function

Timing of Measurement

Tools Used for Measurement

Statistical Significance

Successful Model According to Review Criteria

6 months

NIHSS, TUG, physical test

No

No (four domains)

Days in NH and mortality

No

Yes (one domain)

Institution time and death Quality of life Stroke knowledge, lifestyle changes Health risk management Allen et al., 2002 Neuromotor function

3 months

Institution time and mortality Quality of life

BP, A1c, cholesterol

No

NIHSS, BI, TUG

Yes

CES-D

Yes

SA-SIP30

Yes Yes

BP, INR, number of falls, med check

Yes

Neuromotor function

SSS

No

Balance

BBS

No

Time to walk 5 meters

No

Caregiver Strain Index

No

Mortality

No

Nottingham Health Profile

No

BI

No

Health risk management

Walking speed Askim et al., 2004

No Yes

Study questionnaire

Stroke knowledge

Askim et al., 2006

SSQOL Questionnaire

Caregiver strain

1, 6, 26, and 52 weeks

Mortality Quality of life Independence in ADLs Disability

Yes

No

No

mRS

No

Claiborne, 2006a

Medical care utilization

3 months

ED use vs. PCP visits

Yes

Yes

Claiborne, 2006b

Physical functioning

3 months

SF-36 PCS

No

No (one domain) Yes (three domains)

Mental functioning

SF-36 MCS

Yes

Depression

Geriatric Depression Scale

Yes

Adherence

Observation by MSW

Yes

Nottingham Health Profile

Yes

No (four domains)

Frenchay Activity Index

No

Yes (one domain)

MontgomeryYAshberg

No

MMSE

No

Caregiver Strain Index

No

BI, FIM, TUG

No

Frenchay Arm Test

No

SF-36

No

Carer: depression

Zerssen Depression Scale

No

Carer: somatic problems

Giessen Symptom List

No

Carer: burden

Burden scale, family carer

No

Fjaertoft et al., Quality of life 2004

1 year

Disability Depression Cognitive mental status Caregiver strain Grasel et al., 2005

Independence in ADLs Function of upper extremities Quality of life

6 months

No

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TABLE 2. Transitional Care Outcomes, Measurement, and Statistical Significance, Continued Study

Outcomes

Indredavik et al., 2000

Disability

Timing of Measurement

Tools Used for Measurement

Statistical Significance

Successful Model According to Review Criteria

6 weeks

mRS

No

Yes

Independence in ADLs

6 weeks

BI

No

Disability

26 weeks

mRS

Yes


26 weeks

BI

Yes

Mortality/ institutionalization Joubert et al., 2006

Health risk management

No 1 year

Depression Lincoln et al., 2003


4 and 9 months

IADLs Depression

PHQ-9

Yes

BI

No

Nottingham Extended ADL

No

GHQ-12

No

Study questionnaire

Yes

Satisfaction with program

Study questionnaire

Yes

CSI

No

SF-36-PCS, TUG, gait speed

No

Neuromotor function

1.5 and 6 months

Independence in ADLs Depression Mental functioning

Mayo et al., 2000

Yes for chol. and walks only

Where to get help

Caregiver strain Mayo et al., 2008

BP, cholesterol, walks/week

BI

No

GDS

No

MMSE, SF-36 MCS, EQ-5D, PBSI, RNLI

No

Stroke severity

CNS

No

Health services utilization

ED use and readmissions

No

SF-36 PCS

Yes

Physical functioning Stroke severity

CNS, STREAM

Yes

Disability

TUG, BI, OARS-IADL

Yes

Handicap

RNLI

Yes

Yes

No

No

Yes

Note. A1c = glycolated hemoglobin, BBS = Berg Balance Scale; BI = Barthel Index; BP = blood pressure; CES-D = Center for Epidemiological Studies Depression Scale; CNS = Canadian Neurological Scale; CSI = Caregiver Strain Index; ED = emergency department; EQ-5D = Euroqol Health Questionnaire; FIM = Functional Independence Measure; GDS = Geriatric Depression Scale; GHQ-12 = General Health Questionnaire; IADL = Incidental Activities of Daily Living; MMSE = Mini-Mental Status Examination; mRS = modified Rankin Scale; NIHSS = National Institute of Health Stroke Scale; OARS-IADL = Older American Resource Scale-IADL; PBSI = Preference Based Stroke Index; PCP = primary care provider; PHQ-9 = Patient Health Questionnaire Depression Model; RNLI = Reintegration to Normal Living Index; SA-SIP-30 = Stroke Adapted Sickness Impact Profile; SSQOL = Stroke Specific Quality of Life; SSS = Scandinavian Stroke Scale; SF-36-MCS = Short Form Mental Component Summary; SF-36-PCS = Short Form Physical Component Summary; TUG = Timed Up and Go Test.

stroke, and a decrease in ED utilization were found in only one study each (Table 2).

Discussion This literature review to identify successful transitional care models used with patients after stroke revealed

few published articles to date. The lack of significant outcomes is surprising given that transitional care models have been proven to be effective when tested with patients with other diagnoses (Coleman, Parry, Chalmers, & Min, 2006; Jack et al., 2009; Naylor et al., 2004). This could be explained by (a) use of organized stroke


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units providing comprehensive care, (b) lack of standard definition for transitional care, or (c) lack of consensus on outcome measures. The research shows that patients cared for on organized stroke units after their strokes have improved outcomes in independence, morbidity, and mortality (Stroke Unit Trialists’ Collaboration, 2007). Over 73% of the studies in this review recruited both control and intervention groups from stroke units for their studies (see Table 1). These patients are already more likely to have better outcomes than those treated on a general medical ward because of the highly specialized care they receive. Using a control group that is already receiving all of the seven intervention categories described by the NTOCC (2011) leaves little room for improvement in outcomes. Interventions consisting of one home visit and multiple telephone calls seem unlikely to produce results above and beyond usual care consisting of interdisciplinary team assessments, individualized psychosocial and physical care plans, optimal medication prescriptions, risk factor reduction, stroke education, engaging PCPs, and enhanced discharge planning. For example, in the trial by Allen et al. (2009), the control group as well as the intervention group received organized stroke unit care consisting of interdisciplinary team physical and psychosocial assessments, individualized evidenced-based care plans, completed recommended testing, optimized medication regimens, and a complete discharge plan. A written discharge summary with medications, test results, risk factor profile, discharge plans, and baseline assessment data was then sent to all of the patients’ PCPs. The control group also received stroke education materials in the mail every 2 months. In addition to this detailed program, the intervention group had a home visit within 1 week of discharge to perform a repeat assessment. The interdisciplinary team then formulated care plans as needed, provided physical therapist, and gave a personalized health record to the patient. The patients were then contacted by telephone at least once per week for a month and then once a month until 6 months after discharge for assessment. The study results reported no significant differences between the two groups. A similar design was constructed by Grasel et al. (2005), who concluded that their intensified transition program did not affect the functional status of the patient after stroke. The intervention consisted of two 1-hour seminars to the family caregivers and a therapeutic weekend consisting of a weekend at home accompanied by a home care service that evaluated needed adaptations of the home environment before official discharge. Both control and study groups received identical highly specialized stroke unit care while inpatients. The difference in care provided to the control and study groups seems minimal, with all

major areas of concern taken care of before leaving the stroke units. In only one study did the outcomes measured show significant improvement in each category tested. The randomized controlled trial by Allen et al. (2002) resulted in significant improvements in stroke knowledge, neuromotor functioning, QOL, management of health risk factors, and severe complications. Although this trial was also conducted on a specialized stroke unit, it differed from other studies mentioned. The interdisciplinary team provided individualized treatment plans post discharge for only the study group. Copies of those plans, evidenced based guidelines, and references from the literature to support the planned care were given to the PCPs of the study group. All post discharge care for the control group was planned and provided by their individual PCPs. There was a clear delineation between the transitional care interventions for the study group and the usual care for the control group. The result was statistically significant differences in the measured outcomes. It may well be that the stroke unit’s interdisciplinary teams plan so thoroughly for the patients’ transition to home that little advantage remains to be gained by adding more intervention after discharge. It is not necessarily the case that transitional care has no effect on adverse outcomes in patients with stroke. It may be that the transitional care is being arranged for and some portions of it are implemented, before discharge. This is appropriate as transitioning from one setting to the next includes preparing for discharge. Subgroup analysis in two of the studies revealed significant improvements compared with the study groups as a whole. The study by Allen et al. (2009) showed significant results in the outcomes of stroke knowledge and lifestyle changes, whereas four other outcomes had no significant improvement, including neuromotor function, institution time or death, QOL, and health risk management. However, a subgroup analysis of patients who had atrial fibrillation or experienced a prior stroke or transient ischemic attack (TIA) did show significant improvement in neuromotor function after the study interventions (Allen et al., 2009). In a second study, an improvement in neuromotor function was also shown in a subgroup analysis. Patients with higher baseline National Institute of Health Stroke Scale deficits had a relatively greater improvement in outcome (Allen et al., 2002). These results suggest that subgroup analysis may reveal categories of patients who respond favorably to certain interventions; however, this was not addressed in most studies, and further investigation is warranted. Although the study authors reported few significant results, almost half of the studies reviewed can be considered successful interventions according to the criteria established for this literature review (Table 2). As discussed, the variety of interventions and lack of


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protocols to deliver the interventions prevent identification of specific cause and effects because of any one action. Thus, there is no definite means of translating the data into practice to improve the transitional care of patients with stroke.

Recommendations Components of transitional care may vary depending on the provider. Healthcare professionals have called for a clear definition of transitional care that can be used consistently among all those involved with its design and implementation (Bettger et al., 2012; Cipriano, 2012). Until a consensus is reached, identification of successful interventions is problematic. Currently, transitional care may include any or all of the following: discharge planning, in-home follow-up, telephone support, or patient education at any of the mentioned points of contact. In addition, medication management, transfer of information between providers, prompt PCP follow-up after hospital discharge, and shared accountability for the care of the patient are all considered principal components of transitional care. Yet, the various established transitional care models incorporate different interventions in their models. Clearly identifying interventions that constitute a standardized conceptual model of transitional care would allow targeted outcome measures and more accurate assessment of successful interventions. Consensus also needs to be reached regarding the measures used to evaluate the outcomes of transitional care interventions. This is far more complex than simply choosing whether to use the modified Rankin Scale or the Barthel Index as the measure to evaluate functional independence. The NTOCC Measures Work Group (2008) examined multiple issues involved in measuring transitional care outcomes. Common definitions and terminology are once again identified as a need. The NTOCC suggests ongoing, identical, stepwise approaches to measurement to identify effective interventions. They then recommend narrowing the measurements to individual, team, and facility levels and using a paired sender and receiver approach to accurately reflect accountability. Only the studies by Claiborne (2006b) and Mayo et al. (2008) presented data reflecting a trend in decrease in hospital readmission rates and ED use; however, in neither study was the change statistically significant. In today’s environment, with hospitals subject to penalties from the Centers for Medicare and Medicaid Services for readmission rates deemed too high, it is vital to know healthcare utilization rates and the associated costs. These outcomes need to be measured in every study examining transitional care models because the use of a particular transitional care model may greatly depend on its cost effectiveness.

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Finally, the evidence supporting the use of transitional care models in patients after stroke is sparse and generally outdated. Additional large-scale randomized controlled trials specific to patients with stroke should to be undertaken to provide reliable data regarding effective transitional care interventions. As noted by Bettger et al. (2012), there is a need for these studies to be conducted in the United States within the healthcare system they would ultimately be used to be clinically relevant. The rapidly aging U.S. population places some urgency on the need to increase the knowledge base regarding successful interventions to use in patients with stroke.

Implications of Findings for Neuroscience Nurses Input from neuroscience nurses is invaluable in establishing guidelines for the transitional care of patients with stroke because current criteria by The Joint Commission provide little detail for how to meet standards. Their knowledge of the neurological deficits patients struggle with in their everyday lives will ensure that the standards directly impact the needs of the patient with stroke and his/her family. In addition, neuroscience nurses can contribute to the small existing knowledge base by conducting quality improvement activities specific to the transitional care of patients with stroke. The results will provide evidenced-based data on which to plan and evaluate the transitional care of patients with stroke. In the absence of these data, stroke units and neuroscience nurses should review current policies and procedures to ensure that each of the seven NTOCC intervention categories described earlier are addressed.

References An asterisk indicates an article reviewed for the literature review. *Allen, K., Hazelett, S., Jarjoura, D., Hua, K., Wright, K., Weinhardt, J., & Kropp, D. (2009). A randomized trial testing the superiority of a post-discharge care management model for stroke survivors. Journal of Stroke and Cerebrovascular Diseases, 18(6), 443Y452. http://dx.doi.org/10.1016/j .jstrokecerebrovasdis.2009.02.002 *Allen, K. R., Hazelett, S., Jarjoura, D., Wickstrom, G. C., Hua, K., Weinhard, J., & Wright, K. (2002). Effectiveness of a postdischarge care management model for stroke and transient ischemic attack: A randomized trial. Journal of Stroke and Cerebrovascular Diseases, 11(2), 88Y98. http://dx.doi.org/10.1053/jscd.2002.127106 *Askim, T., Morkved, S., & Indredavik, B. (2006). Does an extended stroke unit service with early supported discharge have any effect on balance or walking speed? Journal of Rehabilitation Medicine, 38, 368Y374. http://dx.doi.org/10.1080/ 16501970600780294 *Askim, T., Rohweder, G., Lydersen, S., & Indredavik, B. (2004). Evaluation of an extended stroke unit service with early supported discharge for patients living in a rural community. A randomized controlled trial. Clinical Rehabilitation, 18, 238Y248. http://dx.doi.org/10.1191/0269215504cr752oa


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Multiple medication use in older patients in post-acute transitional care: a prospective cohort study.

Re: The fate of transitional urology patients referred to a tertiary transitional care center.

Effectiveness of a national transitional care program in reducing acute care use.

Transitional care management in the outpatient setting.

Validation of risk scoring models for predicting stroke-associated pneumonia in patients with ischaemic stroke.

Transitional care in pediatric urology.

Use of Montreal Cognitive Assessment in patients with stroke.

Children's use of inanimate transitional objects in coping with hassles.

Expanding antiplatelet use for patients with stroke: the case for stroke of unknown type.

Adolescent Urology and Transitional Care.

Patients' views on the quality of transitional care at a health insurance hospital in Alexandria, Egypt.

Transitional health care for patients with Hirschsprung disease and anorectal malformations.

Models of primary care for frail patients.

Critical care for patients with massive ischemic stroke.

Reducing bottlenecks: professionals' and adolescents' experiences with transitional care delivery.

Improved outcomes for elderly patients who received care on a transitional care unit.

The use of MMSE and MoCA in patients with acute ischemic stroke in clinical.

Allowing the novice to succeed: transitional support in critical care.

Experimental models of stroke.

Transitional care for the highest risk patients: findings of a randomised control study.

Nurse numbers inadequate for the care of patients following stroke.

Variations in the intensive use of head CT for elderly patients with hemorrhagic stroke.

Effects of a 4-week transitional care programme for discharged stroke survivors in Hong Kong: a randomised controlled trial.

Pharmacists team up for transitional care.