Making improvements in stroke transitions: Identifying problems and solutions Experiences of stroke transitions.

Background And Aims: Stroke survivors often experience fragmented services when transitioning between rehabilitation and community living. Poor interpersonal and inter-agency communication; limited service co-ordination and support for adjustment to life after stroke often cause distress and hospital readmission. This study aimed to explore problematic processes and generate solutions for future implementation and evaluation.
Methods: Community dwelling stroke survivors, their companions, and health, social care and voluntary sector practitioners were purposefully selected to attend a consultation event. Focus groups with stroke survivors and companions, and health and social care professionals separately identified problematic areas in the pathway between rehabilitation and community. Integrated groups then refined and prioritised problems, and envisioned solutions. Analysis occurred through iterative refinement of ideas on the day that was supplemented by post-hoc thematic analysis by two researchers.
Results: Nine stroke survivors, 8 companions and 12 professionals attended. Three overlapping themes emerged: 1) Sense of abandonment stemming from a lack of personalised support post-stroke 2) Difficulties accessing services due to gaps in systems and lack of timely information 3)Health professionals did not facilitate person-centred decision making. Respective solutions were: 1)Availability of peer and professional support to aid adjustment; 2) Availability of a navigator to negotiate transition and community systems; 3) Enhancement of person-centred approaches to care.
Conclusions: This study identified 3 key relational problems that influence how stroke survivors experience transitions. Addressing them and evaluating success of implementation in timely yet rigorous ways will be complex. We will now develop integrated research and quality improvement methods for testing in subsequent project phases.