Transitional Stroke Care and the Road to Recovery

Formalized stroke center care has improved morbidity and mortality from stroke, but transitional care after hospital discharge remains highly variable. This article provides a conceptual framework for transitional stroke care, summarizes data-driven practices, and reviews strategies for the successful implementation of programs that translate to success for patients and care partners.

The ideal transitional stroke care framework is largely driven by protocolized care delivery models aimed at the conduct of efficient diagnostic processes, adherence to effective treatments, and avoidance of common poststroke complications. A large-scale randomized clinical trial testing an early-supported discharge program (COMPASS-TC [Comprehensive Post-Acute Stroke Services transitional care]) was significantly limited by poor uptake, with only 35% of enrolled participants completing the prescribed intervention visit at implementation sites. There have been numerous single-center reports of benefits for hospitalized patients with stroke when postdischarge transitional care is well coordinated. The Joint Stroke Transitional Technology-Enhanced Program, an example of a standardized early supported discharge program, is an interprofessional, specialty program composed of a series of joint telemedicine visits for hospitalized patients with stroke. Using this model has demonstrated high value with the rate of visit completion with the stroke specialist greater than 80%, accelerated access to recovery resources, and lower 30-day hospital readmission rates compared with national standards.

Based on a holistic conceptual framework, implementation of a formalized transitional stroke care model optimizes success for both the patient with stroke and the comprehensive stroke center of care.