Improving stroke transitions: Development and implementation of a social work case management intervention

ABSTRACT

Strokes impact over 800,000 people every year. Stroke care typically begins with inpatient care and then continues across an array of healthcare settings. These transitions are difficult for patients and caregivers, with psychosocial needs going unmet. Our team developed a case management intervention for acute stroke patients and their caregivers aimed at improving stroke transitions. The intervention focusses on four aspects of a successful care transition: support, preparedness, identifying and addressing unmet needs, and stroke education. This paper describes the development and implementation of this program, and is an example of the synergy created between neuroscience and clinical practice.

KEYWORDS:

• Case management
• care transitions
• patient-centered
• randomized controlled trial
• stroke

Acknowledgments

The authors would like to acknowledge our co-investigators Paul Freddolino, Sarah Swierenga, and Constantinos Coursaris. In addition, we acknowledge PCORI for their support of this work. Our thanks go to the entire MISTT team of recruiters, social work case managers, data collectors, hospital coordinators, and advisory board members.

Funding

This work was supported by the Patient-Centered Outcomes Research Institute [IHS-1310-07420-01].

Additional information

Funding

This work was supported by the Patient-Centered Outcomes Research Institute [IHS-1310-07420-01].