Optimizing Hospital-to-home Transitions for Older Adults With Stroke and Multimorbidity: a Pragmatic Randomized Controlled Trial

This research is aimed at improving the experience and quality of transitioning from hospital-to-home for older adults (> 55 years) with multimorbidity (2 or more chronic conditions) and stroke living in the community. Researchers will work collaboratively with the Regional Rehabilitation Centre, Hamilton Health Sciences and the Hotel Dieu Shaver Health and Rehabilitation Centre to adapt, implement and evaluate a person and family-centred hospital-to-home transitional care stroke intervention, the Transitional Care Stroke Intervention (TCSI).

Study participants will be randomly assigned to usual stroke care or the TCSI. The TCSI is a 6-month intervention that is being delivered by an interprofessional team of health care providers from a hospital-based outpatient stroke rehabilitation team, including a registered nurse, occupational therapist, physiotherapist, social worker, and speech language pathologist. The team will develop a comprehensive post-discharge plan, provide regular in-home visits and system navigation, and hold monthly interprofessional case conferences.

The intervention is expected to support the successful re-integration of older adult stroke survivors into the community. Researchers are hoping the focus of the TCSI on system navigation, and promoting self-management and the prevention and management of stroke and other chronic conditions will lead to fewer hospital readmissions, improved health outcomes, and improved patient, caregiver and provider experience.

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