AN INTEGRATED TRANSITIONAL CARE INTERVENTION IMPROVES PATIENT-REPORTED OUTCOMES IN OLDER ADULTS WITH STROKE

Abstract

The transition between hospital and home is associated with significant challenges resulting in hospital readmissions and poor health outcomes. This study aimed to test, in real-world clinical practice, the effectiveness of a Transitional Care Stroke Intervention (TCSI) compared to usual care on patient-reported outcomes and health and social service use costs in older adults (> 55 years) with stroke and multimorbidity (> 2 chronic conditions). The TCSI was delivered virtually by an interprofessional (IP) team, and included care coordination/system navigation support, phone/video visits, monthly IP team conferences, and an online resource co-designed with patient partners to support self-management and system navigation. The primary outcome was risk of hospital readmission after six-months. Secondary outcomes included physical and mental functioning, stroke self-management, patient experience, and health and social service costs. Ninety participants were enrolled (44 intervention, 46 control); 11 (12%) participants were lost to follow-up, leaving 79 (39 intervention, 40 control). Differences favoring the intervention group were seen in physical functioning (SF-12 PCS mean difference: 5.10; 95% CI: 1.58-8.62, p=0.005), self-management (Southampton Stroke Self-Management Questionnaire mean difference: 6.00; 95% CI: 0.51—11.50, p=0.03), and patient experience (Person-Centred Coordinated Care Experiences Questionnaire mean difference: 2.64, 95% CI: 0.81, 4.47, p=0.005). No significant between-group differences were seen for baseline to six-month risk of hospital readmission or total health and social service costs. The TCSI produced greater gains in patient-reported physical health, self-management and experience compared with usual stroke care. These improvements were achieved without increasing total healthcare costs.