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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.

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 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.

* Allen, K., Hazelett, S., Jaijoura, 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), 443-452. .jstrokecerebrovasdis.2009.02.002

* Allen, K. R., Hazelett, S., Jarjoura, D., Wickstrom, G. C., Hua, K., Weinhard, I, & Wright, K. (2002). Elfectiveness of a postdischarge care management model for stroke and transient ischemic attack: A randomized trial. Journal of Stroke and Cerebrovascular Diseases, 11(2), 88-98.

* 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, 368-374. 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, 238-248.

Baggs, J. G., & Schmitt, M. H. (1988). Collaboration between nurses and physicians. Image: Journal of Nursing Scholarship, 20(3), 145-149. Retrieved from

Bettger, J. R, Alexander, K. R, Dolor, R. J., Olson, D. M., Kendrick, A. S., Wing, L., ... Graffagnino, C. (2012). Transitional care after hospitalization for acute stroke or myocardial infarction: A systematic review. Annals of Internal Medicine, 157(6), 407-416. 7-6-201209180-00004

Cipriano, P. (2012). The imperative for patient-, family-, and population-centered interprofessional approaches to care coordination and transitional care: A policy brief by the American Academy of Nursing's Care Coordination Task Force. Nursing Outlook, 60(5), 330-333. j.outlook.2012.06.021

* Claiborne, N. (2006a). Efficiency of a care coordination model: A randomized study with stroke patients. Research on Social Work Practice, 16(1), 57-65.

* Claiborne, N. (2006b). Effectiveness of a care coordination model for stroke survivors: A randomized study. Health and Social Work, 31(2), 87-95.

Coleman, E. A., Pany, C., Chalmers, S., & Min, S. (2006). The care transitions intervention. Archives of Internal Medicine, 166(17), 1822-1828. .17.1822

Enderlin, C. A., McLeskey, M., Rooker, J. L., Steinhauser, C., D'Avolio, D., Gusewelle, R., & Ennen, K. A. (2013). Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatric Nursing, 34(1), 47-52. http://dx.doi.Org/10.1016/j.gerinurse.2012.08.003

* Fjaertoft, H., Indredavik, B., Johnsen, R., & Lydersen, S. (2004). Acute stroke unit care combined with early supported discharge. Long term effects on quality of life. A randomized controlled trial. Clinical Rehabilitation, 18, 580-586.

* Grasel, E., Biehler, J., Schmidt, R., & Schupp, W. (2005). Intensification of the transition between inpatient neurological rehabilitation and home care of stroke patients. Controlled clinical trial with follow-up assessment six months after discharge. Clinical Rehabilitation, 19, 725-736. http://dx.doi .org/10.1191/0269215505cr900oa

* Indredavik, B., Fjaertoft, EL, Ekeburg, G., Loge, A., & Morch, B. (2000). Benefit of an extended stroke unit service with early supported discharge. Stroke, 31, 2989-2994.

Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., ... Culpepper, L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(2), 178-187.

* Joubert, J., Reid, C., Joubert, L., Barton, D., Ruth, D., Jackson, D., ... Davis, S. (2006). Risk factor management and depression post-stroke: The value of an integrated model of care. Journal of Clinical Neuroscience, 13, 84-90.

Kripalani, S., LeFevre, R, Phillips, C. O., Williams, M. V., Basaviah, R, & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. Journal of the American Medical Society, 297(8), 831-841. .297.8.831

* Lincoln, N. B., Francis, V. M., Lilley, S. A., Sharma, J. C., & Summerfield, M. (2003). Evaluation of a stroke family support organiser: A randomized controlled trial. Stroke, 34, 116-121. .33686.32

Makaryus, A. N., & Friedman, E. A. (2005). Patients' understanding of their treatment plans and diagnosis at dis charge. Mayo Clinic Proceedings, 80(8), 983-987. http://dx.doi .org/

* Mayo, N. E., Nadeau, L., Ahmed, S., White, C., Grad, R., Etuang, A., ... Woo-Dauphinee, S. (2008). Bridging the gap: The effectiveness of teaming a stroke coordinator with patient's personal physician on the outcome of stroke. Age and Ageing, 37(1), 32-38.

* Mayo, N. E., Wood-Dauphinee, S., Cote, R., Gayton, D., Carlton, J., Buttery, J., & Tamblyn, R. (2000). There's no place like home: An evaluation of early supported discharge for stroke. Stroke, 31, 1016-1023.

Moore, C, Wisnivesky, J., Williams, S., & McGinn, T. (2003). Medical errors related to discontinuity of care from an inpatient to outpatient setting. Journal of General Internal Medicine, 18(8), 646-651. .20722.x

National Transitions of Care Coalition. (2011). Care transition bundle: Seven essential intervention categories. Retrieved from

Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized controlled trial. Journal of the American Geriatrics Society, 52, 675-684. .2004.52202.x

Naylor, M. D., & Keating, S. A. (2008). Transitional care: Moving patients from one care setting to another. American Journal of Nursing, 108, 58-63. A J.0000336420.34946.3a

NTOCC Measures Work Group. (2008). Transition of care measures. Retrieved from

Peikes, D., Lester, R. S., Gilman, B., & Brown, R. (2013). The effects of transitional care models on re-admissions: A review of the current evidence. Journal of the American Society on Aging, 36(4), 45-54.

Robert Wood Johnson Foundation. (2013). Reducing avoidable readmissions through better care transitions. Retrieved from

Stroke Unit Trialists' Collaboration. (2007). Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews, (4), CD000197.

The Joint Commission. (2009). Stroke core measure set. Retrieved from Stroke.pdf

Tilling, K., Coshall, C., McKevitt, C., Daneski, K., & Wolfe, C. (2005). A family support organiser for stroke patients and their carers: A randomized controlled trial. Cerebrovascular Diseases, 20(2), 85-91.

Questions or comments about this article may be directed to A4. Irene Puhr, DNPARNP, at 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.

DOI: 10.1097/JNN.0000000000000143
TABLE 1. Summary Table of Literature Review Findings Regarding
Transitional Care Model Components

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
                                                      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,
                                                      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

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
                                                      monitor pt.

Claiborne,        Same as         Social workers      Same as above
2006a;            above           (MSW)

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

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

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
                                                      outpatient care
                                                      services, support
                                                      groups; telephone

Joubert et al.,   45 control,     Neurologist, PCP,   Shared care plan
2006; RCT         35 study        study coordinator   to PCP: risk
                                                      factor goals
                                                      based on practice
                                                      Arranged F/U at 2
                                                      weeks and 3, 6,
                                                      9, and 12 months;

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
                                                      provided support
                                                      and information

Mayo et al.,      56 control,     Multidisciplinary   Early DC, home
2000; RCT         58 study        team: nurse, PT,    rehabilitation
                                  OT, ST, and

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
                                                      health promotion,
                                                      stroke knowledge,
                                                      time management,
                                                      support, and
                                                      special services
                                                      and benefits

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

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
                                    with PCP, used
                                    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

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-
                                    program, pt.

Fjaertoft,        Same as above     Same as above     Same as above
Johnsen, &
Lydersen, 2004;

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
                  watch therapy
                  sessions and
                  receive ed.
                  regarding pt.
                  for durable
                  medical aids
                  done; "care
                  report" to home
                  health nursing

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)
                                    use, and
                                    "listening ear"
                                    and emotional

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

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

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

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

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.

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

                                                Timing of
Study                      Outcomes            Measurement

Allen et at, 2009   Neuromotor function         6 months
                    Institution time and
                    Quality of life
                    Stroke knowledge,
                      lifestyle changes
                    Health risk management

Allen et at, 2002   Neuromotor function         3 months
                    Institution time and
                    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
                    Quality of life
                    Independence in ADLs

Claiborne,          Medical care                3 months
2006a                 utilization

Claiborne,          Physical functioning        3 months
2006b               Mental functioning

Fjaertoft et al.,   Quality of life              1 year
2004                Disability
                    Cognitive mental status
                    Caregiver strain

Grasel et al.,      Independence in ADLs        6 months
2005                Function of upper
                    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

Joubert et al.,     Health risk management       1 year
2006                Depression

Lincoln et al.,     Independence in ADLs         4 and 9
2003                                             months
                    Where to get help
                    Satisfaction with
                    Caregiver strain

Mayo et al.,        Neuromotor function          1.5 and
2008                                            6 months
                    Independence in ADLs
                    Mental functioning
                    Stroke severity
                    Health services

Mayo et al.,        Physical functioning
2000                Stroke severity

                                                   Tools Used for
Study                      Outcomes                 Measurement

Allen et at, 2009   Neuromotor function         NIHSS, TUG, physical
                    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
                    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
                    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
                    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
                    Quality of life                    SF-36
                    Carer: depression         Zerssen Depression Scale
                    Carer: somatic problems     Giessen Symptom List
                    Carer: burden               Burden scale, family

Indredavik et at,   Disability                          mRS
2000                Independence in ADLs                 Bl
                    Disability                          mRS
                    Independence in ADLs                 Bl

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
                    Depression                         GHQ-12
                    Where to get help           Study questionnaire
                    Satisfaction with           Study questionnaire
                    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

Study                      Outcomes            Significance

Allen et at, 2009   Neuromotor function             No
                    Institution time and            No
                    Quality of life                 No
                    Stroke knowledge,              Yes
                      lifestyle changes
                    Health risk management          No

Allen et at, 2002   Neuromotor function            Yes
                    Institution time and           Yes
                    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
                    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

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
                    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

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)
                    Quality of life
                    Stroke knowledge,
                      lifestyle changes
                    Health risk management

Allen et at, 2002   Neuromotor function               Yes
                    Institution time and
                    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

Claiborne,          Medical care                      Yes
2006a                 utilization

Claiborne,          Physical functioning        No (one domain)
2006b               Mental functioning        Yes (three domains)

Fjaertoft et al.,   Quality of life            No (four domains)
2004                Disability                 Yes (one domain)
                    Cognitive mental status
                    Caregiver strain

Grasel et al.,      Independence in ADLs              No
2005                Function of upper
                    Quality of life
                    Carer: depression
                    Carer: somatic problems
                    Carer: burden

Indredavik et at,   Disability                        Yes
2000                Independence in ADLs
                    Independence in ADLs

Joubert et al.,     Health risk management            Yes
2006                Depression

Lincoln et al.,     Independence in ADLs              No
2003                IADLs
                    Where to get help
                    Satisfaction with
                    Caregiver strain

Mayo et al.,        Neuromotor function               No
2008                Independence in ADLs
                    Mental functioning

                    Stroke severity
                    Health services

Mayo et al.,        Physical functioning              Yes
2000                Stroke severity

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
Article Type:Report
Date:Aug 1, 2015
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