Transitional Care Models in Stroke Rehabilitation
Summary
Transitional care models in stroke rehabilitation encompass structured approaches to support patients as they move from acute hospital settings to home and community environments. These models seek to maintain continuity of care by integrating comprehensive assessment, individualised care planning and coordinated communication among healthcare providers. Core components often include interprofessional collaboration, timely follow-up contacts (by telephone or face-to-face), tailored self-management education and linkage to community resources for rehabilitation and secondary prevention. Such interventions aim to reduce hospital readmissions, enhance physical function and foster independence in activities of daily living. Globally, rising stroke incidence and resource constraints have driven the adoption of scalable, patient-centred transitional programmes that can be adapted to diverse health systems. Practical implementations have demonstrated improvements in functional recovery and patient experience, although variability in workforce capacity, technological infrastructure and local governance can influence effectiveness and sustainability.
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Transitional Care Models in Stroke Rehabilitation publication trend
The graph below shows the total number of articles in transitional care models in stroke rehabilitation across all publications each year (not limited to Nature Index journals).
Technical terms
Transitional care: Coordination of services and information as patients move between different levels or locations of care.
Interprofessional team: A group of healthcare professionals from varied disciplines working collaboratively with shared goals.
Multidisciplinary team: A collective of specialists from different fields who each contribute discipline-specific expertise to patient care.
Self-management: The process by which patients actively participate in managing symptoms, treatment and lifestyle changes.
Activities of daily living (ADL): Routine tasks essential for personal care, such as dressing, bathing and mobility.
References
- The stroke transitional care intervention for older adults with stroke and multimorbidity: a multisite pragmatic randomized controlled trial. BMC Geriatrics (2023).
- What Type of Transitional Care Effectively Reduced Mortality and Improved ADL of Stroke Patients? A Meta-Analysis. International Journal of Environmental Research and Public Health (2017).
- The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial. BMC Neurology (2017).
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