Perceived Impacts, Facilitators and Barriers to Optimize Hospital-to-Home Transitions for Older adults with Stroke and Multimorbidity through a Virtual Transitional Care Intervention

Abstract

Introduction: Up to 68% of older adults who have suffered a stroke will return to their homes, and 60% will require ongoing care and rehabilitation in the community. Approximately 92% of older adults with stroke have multimorbidity (> 2 chronic conditions). The transition from hospital to home is often poorly managed and fragmented, resulting in hospital readmissions, reduced quality of life, patient satisfaction and safety, and increased caregiver burden. The Transitional Care Stroke Intervention (TCSI) was designed to improve the quality and experience of transitions from hospital to home for older adults (> 55 years) with stroke and multimorbidity and their family caregivers. Evaluation of the implementation and effectiveness of the TCSI is currently in progress in diverse sites in Ontario, Canada. This virtual 6-month intervention is delivered by an interprofessional (IP) team from two hospital-based, outpatient stroke rehabilitation clinics with input from patient research partne