Beyond Early Supported Discharge (ESD): improving and supporting transitions of care after stroke

<p dir="ltr"><b>Background</b><b>: </b>The transition from hospital-to-home after a stroke is complex and often overwhelming for people with stroke and their families, as for many, the concept of organised care disappears. Beyond early supported discharge, studies to date have been limited in informing comprehensive support strategies for this transition.</p><p dir="ltr"><b>Aim</b><b>: </b>The overall aim of the thesis was to develop an evidence-based and stakeholder informed transition-to-home pathway, that addresses key uncertainties in the literature, ensuring a more seamless integration of care at this juncture.</p><p dir="ltr"><b>Method</b><b>: </b>Four studies were included. Study 1 involved updating knowledge by conducting a systematic review and meta-analysis of the available literature around transition-to-home support interventions. In Study 2, the quantitative data allowed us to understand the outcomes and unmet needs of people with stroke at transition and beyond; while in Study 3, the qualitative data allowed us to explore experiences and preferences for supports provided during transitions to home. Integration through interpretation guided each subsequent study, while integration by design approach was used to incorporate findings from Studies 1- 3 into a co-design process to identify feasible components for a stroke transition-to-home intervention (Study 4). Strong emphasis was placed on patient-centred research, involving patient and public involvement (PPI) ‘stroke champions’ and people directly impacted at transitions.</p><p dir="ltr"><b>Results: </b>Study 1 highlights the effectiveness of support interventions in enhancing functional status, albeit amidst uncertainty due to study heterogeneity. Furthermore, it emphasises the absence of core outcome sets, stakeholder input, and standardised development frameworks indicating potential gaps in intervention design. Persistent multi-dimensional unmet needs of people with stroke during transition-to-home are highlighted in Study 2; while themes related to transitional support experiences in Study 3 highlight insufficient communication, information-sharing, and emotional support, and inequitable and fragmented care. Preferences underscore the need for 26 a multifaceted integrated approach, tailored to the needs of people with stroke and their families, highlighting the importance of involving these individuals in discharge planning and care decisions. Finally, Study 4 delineates 10 key elements for person-centred interventions post-stroke, emphasising collaboration, streamlined transition processes, post-discharge follow-up, and the appointment of a stroke coordinator for continuity and care coordination, ultimately delivering a comprehensive pathway to support transition to home following stroke.</p><p dir="ltr"><b>Conclusion: </b>This thesis emphasises the need for person-centred, multi-faceted transition-to-home<br>support interventions for individuals with stroke and their families. It outlines the foundation for an intervention that integrates information, emotional support, care coordination, and follow-up to address unmet needs, promote recovery, and enhance the transition-to-home experience, ensuring it is acceptable to end-users.</p>