Implementation and evaluation of a coordinated care transition focusing on understanding of health information for older people with stroke

The hospital discharge process after stroke is by older people experienced as uncoordinated, forced, and without possibility for participation.

Many patients who have had stroke are discharged with lack of understanding of secondary stroke preventive medication, which is critical to prevent recurrent stroke.

We have together with patients, significant others and hospital and primary care rehabilitation staff developed an intervention that will ensure that patients are prepared for home-coming and have understood health information and how to self-manage secondary prevention medication.The overall aim is to implement and evaluate the co-designed multicomponent care transition intervention.

We hypothesise that a coordinated care transition tailored to support older people’s understanding of health information will improve patient satisfaction with care transitions and patient self-management after hospital discharge, which in turn will reduce recurrent strokes and healthcare utilization.The project targets two phasesNon-randomized controlled trial to evaluate if a multi-component communication intervention has an effect on patient health literacy.

The intervention will be implemented at two hospitals, with two hospitals serving as controls. Data will be collected one-week, 3 months, and 12 months post-discharge. Primary outcome: satisfaction with care transition.

Secondary outcomes: health literacy, medication adherence and recurrent stroke.Mixed-method, process evaluation to identify core components of the intervention that likely can explain the potential effects of the intervention. We will evaluate implementation, dose, and fidelity of the intervention. Data will be collected using questionnaires, administrative data, and interviews.

Interviews will be conducted with intervention patients, significant others, and healthcare professionals.