Background: Inadequate transitional care contributes to poor patient outcomes including hospital readmissions, delayed recovery, and reduced quality of life. We report perspectives from healthcare providers on challenges and stroke educational needs which were collected to inform an intervention study designed to improve stroke transitions following discharge to home.
Methods: During the development phase of the Michigan Stroke Transitions Trial (MISTT), a randomized trial testing a Social Work Case Management (SWCM) intervention, we convened 4 stakeholder meetings with healthcare providers. We aimed to understand provider perspectives regarding patient and system-level challenges and to identify patient educational needs. Michigan providers, including social workers, nurses, neurologists, physiatrists, rehabilitation therapists, and managers were invited to attend the focus groups. Transcriptions were analyzed for common patient and system-level challenges (themes) using qualitative methods and educational needs were determined.
Results: Thirty-four providers, representing hospitals, rehabilitation facilities, nursing homes, and home healthcare agencies, attended the 4 meetings. They identified 43 patient-level, 36 healthcare-level, and 13 community-level challenges. The most common challenges were related to medical follow-up (n=10), consistency of care planning across settings (n=10), ability of patients to retain information (n=10), and unrealistic patient expectations (n=10). The most common stroke educational needs were stroke signs and symptoms recognition (n=10), post-stroke expectations (n=10), stroke risk factors (n=9), and post-stroke depression (n=9). Common medication topics included strategies for medication management (n=13), understanding the importance of medications (n=12), managing side effects (n=7), and communicating with physicians (n=5).
Conclusion: These data were essential in directing the scope and organization of the MISTT case management intervention. Addressing common challenges and targeting stroke educational needs offers the best opportunity for in-home transitional support to maximize stroke recovery during the early transitional period.