Missing Link – Person-centred care transitions for persons who have had stroke. A co-design project
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 multidisciplinary home rehabilitation teams.
About the project Missing Link
The project comprises 3 phases
Phase 1 consists of studies of the current state of care transitions between stroke unit and subsequent home rehabilitation. 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 multidisciplinary home rehabilitation teams in primary care. Workshops with all stakeholders are arranged to pursue the co-design process. In phase 3 the person-centered care transitions developed in phase 2 are implemented and evaluated.
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.
Results
The new care transition from phase 2 consist of:
- Person-centred dialogue and the communication method Teach Back
- Reinforced and structured discharge information
The new care transition has been tested and evaluated in a feasibility study.
Significance
For people who have had a stroke or TIA, self-management and rehabilitation can be a challenge. The challenges include mentally absorbing and processing information in a crisis situation during the short hospital stay. Thus, many patients are discharged with lack of understanding of their health condition and of self-management of secondary prevention. In addition, many patients experience cognitive impairment, depression and fatigue after a stroke. Patients and their significant others may therefore feel unprepared in the subsequent self-management and rehabilitation. Understanding of health condition and self-management is crucial to prevent recurrent stroke and other secondary complications.
Principal Investigator
Charlotte Ytterberg
Senior Lecturer/Physcial TherapistProjektgrupp
Sebastian Lindblom
Postdoctoral ResearcherMartina Bergenroth
Coordinator
Marie Elf
Professor, Högskolan DalarnaAndrea Hess Engström
Affiliated to ResearchMaria Flink
Affiliated to ResearchAnn Charlotte Laska
Affiliated to ResearchMalin Tistad
Affiliated to ResearchLena von Koch
Professor, SeniorPublikationer
Navigating Complexity: Lessons Learned from Co-Designing a Care Transition Intervention for People with Stroke.
Lindblom S, Ytterberg C, Laska AC, Tistad M, Elf M, von Koch L, Flink M
Int J Integr Care 2025 ;25(2):3
Stroke survivors' health literacy is not associated with caregiver burden: a cross-sectional study.
Hess Engström A, Lindblom S, Flink M, Söderberg S, von Koch L, Ytterberg C
Sci Rep 2025 Feb;15(1):4720
Feasibility, Fidelity and Acceptability of a Person-Centred Care Transition Support Intervention for Stroke Survivors: A Non-Randomised Controlled Study.
Lindblom S, Flink M, von Koch L, Laska AC, Ytterberg C
Health Expect 2024 Oct;27(5):e70057
Association between general self-efficacy and health literacy among stroke survivors 1-year post-discharge: a cross-sectional study.
Hess Engström A, Flink M, Lindblom S, von Koch L, Ytterberg C
Sci Rep 2024 Mar;14(1):7308
A person-centred care transition support for people with stroke/TIA: A study protocol for effect and process evaluation using a non-randomised controlled design.
Lindblom S, Flink M, von Koch L, Tistad M, Stenberg U, Elf M, Carlsson AC, Laska AC, Ytterberg C
PLoS One 2024 ;19(3):e0299800
Health literacy is associated with less depression symptoms, higher perceived recovery, higher perceived participation, and walking ability one year after stroke - a cross-sectional study.
Flink M, Lindblom S, von Koch L, Carlsson AC, Ytterberg C
Top Stroke Rehabil 2023 Feb;():1-7
The Use of Teach Back at Hospital Discharge to Support Self-Management of Prescribed Medication for Secondary Prevention after Stroke-Findings from A Feasibility Study.
Lindblom S, Ytterberg C, Flink M, Carlsson AC, Stenberg U, Tistad M, von Koch L, Laska AC
Healthcare (Basel) 2023 Jan;11(3):
Person-centred care transitions for people with stroke: study protocol for a feasibility evaluation of codesigned care transition support.
Flink M, Lindblom S, Tistad M, Laska AC, Bertilsson BC, Wärlinge C, Hasselström J, Elf M, von Koch L, Ytterberg C
BMJ Open 2021 12;11(12):e047329
Referral-based transition to subsequent rehabilitation at home after stroke: one-year outcomes and use of healthcare services.
Lindblom S, Tistad M, Flink M, Laska AC, von Koch L, Ytterberg C
BMC Health Serv Res 2022 May;22(1):594
The manifestation of participation within a co-design process involving patients, significant others and health-care professionals.
Lindblom S, Flink M, Elf M, Laska AC, von Koch L, Ytterberg C
Health Expect 2021 Mar;():
Defining the characteristics of intermediate care models including transitional care: an international Delphi study.
Sezgin D, O'Caoimh R, O'Donovan MR, Salem MA, Kennelly S, Samaniego LL, et al
Aging Clin Exp Res 2020 May;():
Perceived Quality of Care Transitions between Hospital and the Home in People with Stroke.
Lindblom S, Flink M, Sjöstrand C, Laska AC, von Koch L, Ytterberg C
J Am Med Dir Assoc 2020 Jul;():
Perceptive Dialogue for Linking Stakeholders and Units During Care Transitions - A Qualitative Study of People with Stroke, Significant Others and Healthcare Professionals in Sweden.
Lindblom S, Ytterberg C, Elf M, Flink M
Int J Integr Care 2020 Mar;20(1):11
Perceived quality of care transitions between hospital and the home - a cross sectional study. International Journal of Integrated Care. 2018;18(S2): A317, pp. 1-8.
Lindblom S, Flink M, von Koch L, Ytterberg C.
Int J Integr Care 2020 Mar;20(1):11
Person-centered transitions for people with stroke - are we doing enough? A Swedish example.
Lindblom S, Flink M, von Koch L, Ytterberg C.International Journal of Stroke. 2018;Volume: 13 Special Issue: SI Supplement: 3 Pages: 18-18.
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Photo: n/aCharlotte Ytterberg och Sebastian Lindblom medverkar i podcasten "Fysion säger..."
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