Background: Inadequate stroke transitions adversely affect survivors, caregivers and families, contributing to hospital readmissions, recurrent stroke, and poor quality of life. Unfortunately few evidence-based transitional care programs exist for stroke. We report preliminary experience with a patient-centered Social Work Case Management (SWCM) program, including frequency and type of unmet patient needs and duration of case management services.
Methods: The Michigan Stroke Transitions Trial (MISTT) is a pragmatic randomized trial testing the efficacy of an in-home SWCM program against Usual Care for improving stroke survivor and caregiver recovery experiences. The 60 day intervention offers patient-centered case management services addressing psychosocial and medical needs to improve quality of life and increase patient activation and self-management. The SWCM program is designed to address patient identified unmet needs and includes providing support, improving preparedness, and managing stroke prevention.
Results: During the first 6 months, 46 patients were randomized to the SWCM intervention group. Initial assessments were initiated a median of 5 days after returning home. Twenty-five patients (56%) identified at least one unmet need during the initial assessment. The mean number of unmet needs was 1.7 (range 0-10) and covered a wide range of psychosocial (n=9) and medical (n=5) domains. Mental health (22%), symptoms requiring assistance (20%), and monthly expenses (20%) were the most common unmet needs. Among cases who completed the intervention (n=35), the intervention duration ranged from 18-118 days (mean= 69). For 8 of these cases (22%) case management exceeded 60 days. Total case interaction time averaged 5.5 hours (0.5 to 21 hours) and communication occurred across diverse individuals and organizations.
Conclusion: Psychosocial unmet needs are prevalent among stroke survivors during the first 60 days of in-home recovery. These needs require considerable time to manage and involve communication across multiple service organizations. Given the complexity of in-home stroke transitions, stroke survivors can benefit from short-term case management, with some cases requiring longer term management.