Missing Link – Person-centred care transitions for persons who have had stroke. A co-design project

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.