Introduction: In the past two decades, there has been 84% increase of stroke prevalence in China. Since transitional care facilities are lacking in China, most of the stroke survivors return home after discharged from acute hospital setting. Routine disease-oriented discharge planning does not match individual home care needs.
Objective: To evaluate the effectiveness of a modified home care (HC) intervention to facilitate the transition of care for stroke survivors from hospital to home.
Methods: Using a quasi-experimental study design, stroke survivors from a 115-bed stroke unit in teaching hospital in China were recruited. HC subjects (n=168) received nurse-led pre-discharge preparation and post-discharge follow-ups, which beganon admission until 30-days post hospital discharge(a total of 4 hours,5 sessions,48 minutes on average). Hospital length of stay (LOS), stroke-related readmission rates, ability to perform activities of daily living (ADLs), and medication adherence were assessed at 30-days post-discharge. Historical controls (n=173)that received routine discharge planning, including standardized patient education about stroke and one telephone follow-up, were used as the comparison group (CG).
Results: Subjects were on average 65.10 years old, 51% women, 74% ischemic stroke, 26% hemiparesis. The HC group had significantly better outcomes with a reduced hospital LOS(HC=11.3±2.2days vs.CG=12.4±4.3 days, p = 0.03), decreased stroke-related readmission rate(HC=1.2% vs.CG=6.4%, p = 0.02), increased ability to perform ADLs observed by Barthel Index. (HC=38.3±10.2vs.CG=32.1±10.3, p = 0.03) and medication adherence (HC=95.8%vs.CG=53.2%, p = 0.004), compared to CG.
Conclusions: Our findings suggest that the modified HC intervention, incorporating nursing care planning and follow-ups across care settings, is effective in enhancing the transition from hospital to home, in terms of hospital care utilization and patient outcomes.