About the project - Missing Link

The overall aim is to develop, implement and evaluate person-centred care transitions between the stroke unit and the home for persons who have had stroke. The development is carried out in collaboration with persons who have had stroke, significant others, staff at stroke units and interdisciplinary home rehabilitation teams.

The project comprises 3 phases

 

Missing link project

Phase 1

Phase 1 consists of studies of the current state of care transitions between stroke unit and subsequent home rehabilitation:

Qualitative studies to identify facilitators and barriers for person-centred care transitions.

A longitudinal observational study of current care transitions between stroke unit and the home with subsequent home rehabilitation, including outcome of persons with stroke and significant others, and utilization of healthcare services, during the first year after stroke.

Phase 2

Based on knowledge from phase 1 regarding facilitators and barriers a new person-centred care transition between the stroke unit and the home is developed in phase 2. The development is carried out in collaboration with persons who have had stroke, significant others and staff at stroke units and interdisciplinary home rehabilitation teams in primary care. Workshops with all stakeholders are arranged to pursue the co-design process. The co-design process comprises six steps:

  1. Engage: establish a relationship between the participants: people with stroke, significant others, stroke unit staff, and primary healthcare rehabilitation team members to highlight the importance of collaboration in the design of the new health service – person-centred transitions.
  2. Plan: work with participants to generate ideas and goals for the transition process between the stroke unit, the home environment, and the rehabilitation teams from primary healthcare.
  3. Explore: learn about participants’ experiences of the transition from the stroke unit to the home environment, and the rehabilitation teams in primary healthcare.
  4. Develop: turn ideas into specific improvements.
  5. Decide: choose what improvements to make, and how to make them.
  6. Change: put the decided improvements into action.

Phase 2 - Workshops

Phase 3

In phase 3 the person-centered care transitions developed in phase 2 are implemented and evaluated. The new multi-component care transitions consist of:

  • Person-centred dialogue and the communication method Teach Back
  • Reinforced and structured discharge information
  • Bridging e-meeting between the patient, their significant other and the neurorehabilitation team that will continue the rehabilitation in the home-setting.

All healthcare staff will receive education in person-centred care and Teach Back. They will also have practical training with each other and members of the project using fictive cases. In short, the method consists of individualized information based on the patient’s needs and thoughts, and by asking the patient to repeat the information make sure that the most important information has been understood.

The new care transition has been tested and evaluated in a feasibility study. The effects of the new care transition are evaluated in a study where the acute stroke unit and the geriatric ward at Danderyds sjukhus are intervention units. The acute stroke unit at Södersjukhuset and a geriatric ward at Dalens sjukhus are control units.

The process of how the new person-centred care transitions become part of the ordinary work, and if and how they are maintained in practice are studied over the course of one year.