Stroke survivors with multiple chronic conditions (MCC) move between multiple care settings, and so they are at high risk of receiving fragmented care leading to increased risk for avoidable illness, death, and health care costs. Recent Canadian studies and reports identify significant gaps in the delivery of effective stroke care to stroke survivors with MCC in community-based settings. Most stroke rehabilitation programs and guidelines are entirely focused on stroke only and do not address the challenges to patients and providers of managing comorbid conditions.
This pragmatic mixed methods randomized controlled trial evaluated the effectiveness of a community navigation and rehabilitation intervention on HRQOL, depression, anxiety, community reintegration, number of strokes, physical functioning, and the costs of use of health services for stroke survivors with MCC receiving home care and their family caregivers. The results inform: (1) the development of national standards for community-based stroke rehabilitation and (2) the development of a new and innovative community-based model for stroke rehabilitation that can be adapted and implemented for stroke survivors with MCC across Canada.
Publication in Journal of Comorbidity