The majority of the 1 million stroke patients discharged from US hospitals every year return to their homes. For many stroke patients and caregivers, navigating the transition between the hospital and home is associated with substantial emotional, social, and health-related challenges. These challenges are intensified by the abrupt nature of stroke, short hospital stays (typically less than 5 days), and the multiple care settings that patients may use after leaving the hospital (rehabilitation, skilled nursing, home health care). Poor transitions in stroke patients often result in hospital readmissions, slow recovery, poor quality of life, dissatisfaction with care, and caregiver stress.
Social workers play a vital role in healthcare systems by advocating for clients, providing counseling, and coordinating services to bridge the transition from hospital to home. During home visits, social workers can learn valuable information about the complex social and medical needs of patients, resulting in greater opportunities to improve their transitional care experience. Our proposed research program aims to improve the experience of stroke patients after they return home through the development of a patient- and caregiver-centered case management program delivered by Social Work Bridge Coordinators (SWBC). The project will ask stroke patients and caregivers about their experiences after they left the hospital and returned home to ensure that this home-based intervention matches their needs and preferences. We anticipate that this personalized case management program will reduce patient and caregiver needs, improve quality of life, and decrease caregiver stress.
Access to accurate information is critical to patients and caregivers during the transitional care period. The ideal information resource needs to be responsive and adaptable to changing patient needs during the transition period and to the stroke recovery process itself. We will ask stroke patients and caregivers about their information needs after they returned home to develop a patient-centered online communication, information, and support resource called a Virtual Stroke Support Portal (VSSP).
We will test the efficacy of these two complementary interventions in 480 acute stroke patients discharged from four Michigan hospitals. Patients will be randomly assigned to one of the following three groups: (1) usual care, (2) the SWBC case management program, and (3) the SWBC plus the VSSP. We will examine outcomes identified as important by stroke patients and caregivers.
Efforts to redesign health systems by focusing on the entire “episode of care” demand improvements in the care patients receive after they return home. At the end of this three-year project, we will have developed and tested two patient-centered interventions that can be replicated on a larger scale and are designed to improve transitions and outcomes for stroke patients who have returned home.
In Care Transitions, a Chance to Make or Break Patients' Recovery - A narrative on what happens when patients are harmed by poorly executed transitions between healthcare settings.