The missing link- development and evaluation of person-centred transitions from the stroke unit to the home with continued rehabilitation in the home environment – a co-design project

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The overarching aim of the Missing Link project is to design, implement and evaluate coordinated person-centered transitions between stroke units and rehabilitation in the home for people with a mild to moderate stroke in order to reduce lengths of hospital stays, deaths or dependency in activities of daily living (ADL), institutionalization and improve satisfaction with services. Person-centered implies that the person with stroke, his/her significant others and health professionals are partners in the planning, the decision making and in effecting the transition.


A phased approach, as recommended for development and evaluation of complex interventions, will be used. In phase 1 the current transitions from stroke units to the home environment will be explored and facilitators / barriers to coordinated person-centered safe transitions will be identified. Knowledge generated in phase 1 will inform phase 2; a co-design process of new coordinated person-centered transitions conducted by people with stroke, significant others and staff from stroke units and interdisciplinary home rehabilitation teams together. Knowledge from phase 1 and phase 2 will inform phase 3; implementation and evaluation of the missing link. 


The Missing Link builds on the view that the involvement of the users – people with stroke, significant others and the staff at the stroke unit and the interdisciplinary home rehabilitation team - in a design process based on their knowledge and identified needs and in which they together collaborate to design new health services is likely to better meet the users’ needs as well as be realistic with regard to what can be provided by the health care staff. Accordingly the Missing Link adheres to an enabling service model that is centered on co-creation/collaboration in the development of a new health service rather than to a top down service delivery model, which has been proposed to better support improvement and implementation of evidence in health services. Thus in the Missing Link project people with stroke, their significant others, the interdisciplinary team and staff are to be included as partners, experts and co-creators of the new transitions. Such involvement in research has the potential to better identify and reconceptualise problems and incorporate the experiences of the users.

Principal investigator

Charlotte Ytterberg