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-centred care transitions developed in phase 2 are implemented and evaluated. The new care transitions are successively implemented at acute stroke units and geriatric stroke units at Danderyd Hospital and Karolinska University Hospital and corresponding home rehabilitation teams in primary care. 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.