The use of transitional care models in patients with stroke.
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
Patients 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 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) 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 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.
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.
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 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 community-based 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 provided. The control groups then received care as directed by the PCP.
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 oiganizers 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 Montgomery-Ashberg 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 stroke, and a decrease in ED utilization were found in only one study each (Table 2).
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 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 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.
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.
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.
An asterisk indicates an article reviewed for the literature review.
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Questions or comments about this article may be directed to A4. Irene Puhr, DNPARNP, at email@example.com. She is an Adult-Gerontology 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.
TABLE 1. Summary Table of Literature Review Findings Regarding Transitional Care Model Components Author, Date; Design Sample Size Facilitator Intervention Type Allen et al., 190 control, APN; PCP; Individualized 2009; RCT 190 study interdisciplinary care plans, team: OT, PT, DC planning, ST, SW medication reconciliation, DC summary to PCP, baseline assessment by APN, practice guidelines, care plan to PCP Allen et al., 46 control, APN, Individualized 2002; RCT 47 study interdisciplinary care plans, DC team, PCP planning, DC summary to PCP, baseline assessment by APN, practice guidelines, care plan to PCP Askim et al., 31 control, Nurse, Early supported 2004; RCT 31 study interdisciplinary DC, home-based team (OT and PT, rehabilitation mobile stroke program, mobile team) and primary stroke team goes healthcare system to home Askim et al., 31 control, Same as above Same as above; 2006; RCT 31 study early, intensive task-specific therapy Claiborne, 12 control, Social workers Assess QOL, 2006b; 16 study (MSW) health status, randomized mental health, precomparison service needs, and and entitlements; postcomparison coordinate services; educate caregivers; monitor pt. progress Claiborne, Same as Social workers Same as above 2006a; above (MSW) randomized precomparison and postcomparison Indredavik, 160 control, Nurse, mobile Early supported Fjaertoft, 160 study stroke team (OT, DC, home-based Ekeburg, Loge, PT, MD), primary rehabilitation & Morch, 2000; healthcare system program, mobile RCT stroke team home visits, report to PCP with care suggestions Fjaertoft, Same as Nurse, mobile Same as above Indredavik, Indredavik stroke team (OT, Johnsen, & et al. (2000) PT, MD), primary Lydersen, 2004; above healthcare system RCT Grasel, 29 control, Professional Therapeutic Biehler, 33 study carers, male weekend care; pt. Schmidt, & nurses qualified and caregiver ed. Schupp, 2005; in neuro and regarding home controlled rehabilitation, care; ed. clinical trial PT, nurses regarding caregiving burden, outpatient care services, support groups; telephone counseling Joubert et al., 45 control, Neurologist, PCP, Shared care plan 2006; RCT 35 study study coordinator to PCP: risk factor goals based on practice guidelines. Arranged F/U at 2 weeks and 3, 6, 9, and 12 months; telephone assessment Lincoln, 124 control, FSO, Pt. ed. regarding Francis, 126 study multidisciplinary stroke, Lilley, Sharma, team referred to entitlements; & Summerfield, but not described assisted with DC 2003; RCT planning and arrangements; provided support and information regarding resources Mayo et al., 56 control, Multidisciplinary Early DC, home 2000; RCT 58 study team: nurse, PT, rehabilitation OT, ST, and dietician Mayo et al., 94 control, Geriatric nurses Case 2008 96 study management, hospital summary to PCP, arranged F/U with PCP Tilling et al., 168 control, FSO FSO trained in 2005; RCT 168 study PT, secondary prevention, health promotion, stroke knowledge, time management, emotional support, and special services and benefits system Author, Control/Usual Intensity/ Date; Design Care Methods Used Duration Allen et al., PCP received In-home visit Begun at 1 2009; RCT pt. summary, by APN, week: weekly med telephone calls x4, monthly x5 reconciliation, by APN, extra and APN; total DC plans and telephone calls intervention = APN initial as needed by 6 months assessment APN, APN attended PCP visits, stroke ed. and personal health record, PT, home visits by APN Allen et al., Care by PCP, no In-home visit Home visit by 1 2002; RCT DC care plan, by APN, month, 3-month telephone calls telephone calls evaluation by APN, 3-7 days evidence-based post-DC, total protocols, APN intervention = worked 3 months collaboratively with PCP, used guidelines, care plan to PCP, letter with plan of care to pt. Askim et al., Inpt stroke In-home visit ASAP, then 2004; RCT unit and by PCP x2; within 4 weeks; rehabilitation pre-DC family, pt. evaluated doctor, stroke at 6, 26, and team meeting; 52 weeks telephone calls by mobile team; local support group meetings Askim et al., Same as above Same as above Same as above 2006; RCT Claiborne, F/U treatment In-home visit Home visit at 2006b; as determined by MSW, 1-2 weeks, randomized by PCP telephone calls telephone calls precomparison by MSW, ed. and weekly for 20- and support 60 minutes, postcomparison services total intervention = 3 months Claiborne, Same as above Same as above Same as above 2006a; randomized precomparison and postcomparison Indredavik, Inpt stroke Pre-DC family Meeting ASAP, Fjaertoft, unit and Inpt meeting with F/U mobile team Ekeburg, Loge, rehabilitation mobile team, x1 month, group & Morch, 2000; home visit with meeting at 3 RCT mobile team and months PC health system, home- based rehabilitation program, pt. ed. Fjaertoft, Same as above Same as above Same as above Indredavik, Johnsen, & Lydersen, 2004; RCT Grasel, Social service Pre-DC Home 1 weekend Biehler, assistance with weekend at before DC, 3 x Schmidt, & forms, in-home home with 45-to 60- Schupp, 2005; care, etc.; assist, nurses minute classes, controlled self-help and at bedside, 1 before DC, clinical trial support group group seminar clinic visit at referrals; 3 months caregivers watch therapy sessions and receive ed. regarding pt. care; applications for durable medical aids done; "care relocation report" to home health nursing service Joubert et al., Received same Flow charts to Faxed 2006; RCT 12-month record data, information Q 3 evaluation as references from months; missed study group literature; appointments telephone call, tracked and screening for rescheduled. QOL, Telephone calls depression 1 week before each PCP visit and after each appointment to assess changes in care. Lincoln, No records kept Inpt visit One visit each Francis, of within 2 weeks, with pt. and Lilley, Sharma, interventions attended case carer; at least & Summerfield, provided to conferences, 1 time, then as 2003; RCT control; no liaison with needed. Varied description of rehabilitation among pts. usual care team and Frequency caregivers, unclear. home visits made by FSO Mayo et al., Current Individualized 4-week 2000; RCT practices at and duration; home hospitals with coordinated by visit at least acute stroke PT or nurse, 1 time, then as teams; PT, OT, home visits needed. Varied and ST as among pts. ordered by PCP Mayo et al., Instructed to Home visits, 6-week 2008 make F/U telephone duration, appointment and calls, 24-hour average of 4.8 given names if contact home visits no PCP Tilling et al., Provide Varied number 2005; RCT information of contacts regarding (range = 1-60) stroke, secondary prevention, medications use, and entitlements. Provide "listening ear" and emotional support Author, Date; Design Outcome Measures Comments Allen et al., Neuro Fxn: NIHSS, Before DC, pt. 2009; RCT Timed Up and Go had SW and quality of life: SSQOL; PT arranged time in nursing home and PCP or death; questionnaire received DC to test stroke/health summary. Use knowledge; risk of stroke management: BP, unit with cholesterol, enhanced DC depression, meds planning left little room for outcome improvement. Allen et al., Neuro Fxn: NIHSS, Intervention 2002; RCT BI; depression: CES-D; group clearly 30-item Stroke superior, Adapted Sickness p < .0001 Impact Profile; management of health risks; stroke knowledge Askim et al., Disability: Mod. No significant 2004; RCT Rankin, BI; subjective differences in health: Nottingham outcome. Health Profile (NHP); Caregiver Strain Index (CSI) Askim et al., Berg Balance No significant 2006; RCT Scale, walking differences in speed outcome. Claiborne, QOL, physical Significant 2006b; and mental: improvement randomized Short Form-36 in depression precomparison (SF-36); and mental and depression: QOL. Also postcomparison Geriatric improved Depression health risk Scale (GDS); management. health risks Used a management self-report survey to assess outcome. Claiborne, Number of visits Self-report 2006a; reported by pt. data not randomized to medical highly precomparison professional accurate. Did and used to calculate not know postcomparison data. Inpt visits charges, used used actual a mean reimbursement amount. data. $1000 savings per pt. Indredavik, Measured at 6 Extended Fjaertoft, and 26 weeks; stroke unit Ekeburg, Loge, independence: service & Morch, 2000; mRS and BI; % outcomes RCT institutionalized; better than length of stay ordinary in institutions stroke unit service Fjaertoft, Measured at Significant Indredavik, 52 weeks; QOL: NHP; positive Johnsen, & neuro fxn: Frenchay results for Lydersen, 2004; Activity Index; QOL only, RCT depresssion: trending Montgomery-Ashberg toward scale, MMSE; CSI significance on other outcomes. Grasel, Assessed at 6 months; The "usual" Biehler, neuro fxn: BI, Fxn transition care Schmidt, & Independence is so thorough Schupp, 2005; Measure, Timed Up it appears controlled and Go, Ashworth there is little clinical trial Spastic Scale, room for Frenchay Arm Test; improvement. QOL: SF-36; Article does caregiver stress: not supply Zerssen Dep. Scale, information on burden scale for who provided family; Giessen the various symptom list, services. self-assess Joubert et al., Measured at 3 months: Better BP and 2006; RCT meds, BP, lab tests, lipid control, carotid stenosis. adherence to Measured at 12 months: exercise at QOL, Aqol, CSI, 3 months. social support survey; 12 months: Frenchay aphasia test, same as above. MMSE, mRS, BI, London Much less Handicap scale; access depression in to community services study group. Lincoln, Measured at 4 and Assessments done by Francis, 9 months. Mood: questionnaires mailed Lilley, Sharma, Gen. Health Quest to home; positive & Summerfield, (GHQ-12); neuro fxn: increase in knowledge 2003; RCT BI, Nottingham EADL; of stroke. No information regarding significant how to access comm. improvement in mood, services; satisfaction ADLs, or decrease in with FSO; caregivers: caregiver strain. CSI and GHQ-12 Mayo et al., Measured at 1, 2, and Extremely detailed and 2000; RCT 3 months. Neuro fxn: descriptive. Study SF-36, CNS, STREAM, group superior TUG, BI, BADL, and physical health, QOL, OARS-IADL; RNLI, and IADL. disability: RNLI Mayo et al., Measured baseline, Study group had no 2008 6 weeks, 6 months: difference in ed., SF-36; RNLI, BI, TUG, hospital readmissions, GDS; utilization of or QOL. healthcare services Tilling et al., Measured at 3 months Postal questionnaires 2005; RCT and 1 year: RNLI, or home visit used to hospital depression & evaluate significant anxiety scale, BI, CSI, increase in satisfaction and Pound Satisfaction with services and Scale; major outcome: increased utilization of pt. satisfaction; social services. emotional outcomes; utilization of healthcare services 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. TABLE 2. Transitional Care Outcomes, Measurement, and Statistical Significance Timing of Study Outcomes Measurement Allen et at, 2009 Neuromotor function 6 months Institution time and death Quality of life Stroke knowledge, lifestyle changes Health risk management Allen et at, 2002 Neuromotor function 3 months Institution time and mortality Quality of life Stroke knowledge Health risk management Askim et al., Neuromotor function 2006 Balance Walking speed Askim et al., Caregiver strain 1, 6, 26, and 2004 52 weeks Mortality Quality of life Independence in ADLs Disability Claiborne, Medical care 3 months 2006a utilization Claiborne, Physical functioning 3 months 2006b Mental functioning Depression Adherence Fjaertoft et al., Quality of life 1 year 2004 Disability Depression Cognitive mental status Caregiver strain Grasel et al., Independence in ADLs 6 months 2005 Function of upper extremities Quality of life Carer: depression Carer: somatic problems Carer: burden Indredavik et at, Disability 6 weeks 2000 Independence in ADLs 6 weeks Disability 26 weeks Independence in ADLs 26 weeks Mortality/ institutionalization Joubert et al., Health risk management 1 year 2006 Depression Lincoln et al., Independence in ADLs 4 and 9 2003 months IADLs Depression Where to get help Satisfaction with program Caregiver strain Mayo et al., Neuromotor function 1.5 and 2008 6 months Independence in ADLs Depression Mental functioning Stroke severity Health services utilization Mayo et al., Physical functioning 2000 Stroke severity Disability Handicap Tools Used for Study Outcomes Measurement Allen et at, 2009 Neuromotor function NIHSS, TUG, physical test Institution time and Days in NH and death mortality Quality of life SSQOL Stroke knowledge, Questionnaire lifestyle changes Health risk management BP, A1 c, cholesterol Allen et at, 2002 Neuromotor function NIHSS, Bl, TUG Institution time and CES-D mortality Quality of life SA-SIP30 Stroke knowledge Study questionnaire Health risk management BP, INR, number of falls, med check Askim et al., Neuromotor function SSS 2006 Balance BBS Walking speed Time to walk 5 meters Askim et al., Caregiver strain Caregiver Strain Index 2004 Mortality Mortality Quality of life Nottingham Health Profile Independence in ADLs Bl Disability mRS Claiborne, Medical care ED use vs. PCP visits 2006a utilization Claiborne, Physical functioning SF-36 PCS 2006b Mental functioning SF-36 MCS Depression Geriatric Depression Scale Adherence Observation by MSW Fjaertoft et al., Quality of life Nottingham Health 2004 Profile Disability Frenchay Activity Index Depression Montgomery-Ashberg Cognitive mental status MMSE Caregiver strain Caregiver Strain Index Grasel et al., Independence in ADLs Bl, FIM, TUG 2005 Function of upper Frenchay Arm Test extremities Quality of life SF-36 Carer: depression Zerssen Depression Scale Carer: somatic problems Giessen Symptom List Carer: burden Burden scale, family carer Indredavik et at, Disability mRS 2000 Independence in ADLs Bl Disability mRS Independence in ADLs Bl Mortality/ institutionalization Joubert et al., Health risk management BP, cholesterol, 2006 walks/week Depression PHQ-9 Lincoln et al., Independence in ADLs Bl 2003 IADLs Nottingham Extended ADL Depression GHQ-12 Where to get help Study questionnaire Satisfaction with Study questionnaire program Caregiver strain CSI Mayo et al., Neuromotor function SF-36-PCS, TUG, gait 2008 speed Independence in ADLs Bl Depression GDS Mental functioning MMSE, SF-36 MCS, EQ-5D, PBSI, RNLI Stroke severity CNS Health services ED use and utilization readmissions Mayo et al., Physical functioning SF-36 PCS 2000 Stroke severity CNS, STREAM Disability TUG, Bl, OARS-IADL Handicap RNLI Statistical Study Outcomes Significance Allen et at, 2009 Neuromotor function No Institution time and No death Quality of life No Stroke knowledge, Yes lifestyle changes Health risk management No Allen et at, 2002 Neuromotor function Yes Institution time and Yes mortality Quality of life Yes Stroke knowledge Yes Health risk management Yes Askim et al., Neuromotor function No 2006 Balance No Walking speed No Askim et al., Caregiver strain No 2004 Mortality No Quality of life No Independence in ADLs No Disability No Claiborne, Medical care Yes 2006a utilization Claiborne, Physical functioning No 2006b Mental functioning Yes Depression Yes Adherence Yes Fjaertoft et al., Quality of life Yes 2004 Disability No Depression No Cognitive mental status No Caregiver strain No Grasel et al., Independence in ADLs No 2005 Function of upper No extremities Quality of life No Carer: depression No Carer: somatic problems No Carer: burden No Indredavik et at, Disability No 2000 Independence in ADLs No Disability Yes Independence in ADLs Yes Mortality/ No institutionalization Joubert et al., Health risk management Yes for chol. 2006 and walks only Depression Yes Lincoln et al., Independence in ADLs No 2003 IADLs No Depression No Where to get help Yes Satisfaction with Yes program Caregiver strain No Mayo et al., Neuromotor function No 2008 Independence in ADLs No Depression No Mental functioning No Stroke severity No Health services No utilization Mayo et al., Physical functioning Yes 2000 Stroke severity Yes Disability Yes Handicap Yes Successful Model According to Study Outcomes Review Criteria Allen et at, 2009 Neuromotor function No (four domains) Institution time and Yes (one domain) death Quality of life Stroke knowledge, lifestyle changes Health risk management Allen et at, 2002 Neuromotor function Yes Institution time and mortality Quality of life Stroke knowledge Health risk management Askim et al., Neuromotor function No 2006 Balance Walking speed Askim et al., Caregiver strain No 2004 Mortality Quality of life Independence in ADLs Disability Claiborne, Medical care Yes 2006a utilization Claiborne, Physical functioning No (one domain) 2006b Mental functioning Yes (three domains) Depression Adherence Fjaertoft et al., Quality of life No (four domains) 2004 Disability Yes (one domain) Depression Cognitive mental status Caregiver strain Grasel et al., Independence in ADLs No 2005 Function of upper extremities Quality of life Carer: depression Carer: somatic problems Carer: burden Indredavik et at, Disability Yes 2000 Independence in ADLs Disability Independence in ADLs Mortality/ institutionalization Joubert et al., Health risk management Yes 2006 Depression Lincoln et al., Independence in ADLs No 2003 IADLs Depression Where to get help Satisfaction with program Caregiver strain Mayo et al., Neuromotor function No 2008 Independence in ADLs Depression Mental functioning Stroke severity Health services utilization Mayo et al., Physical functioning Yes 2000 Stroke severity Disability Handicap Note. A1c = glycolated hemoglobin, BBS = Berg Balance Scale; Bl = 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 Dally 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.
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|Author:||Puhr, M. Irene; Thompson, Hilaire J.|
|Publication:||Journal of Neuroscience Nursing|
|Date:||Aug 1, 2015|
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