The Missing Link- Development and Feasibility Evaluation of Person-centred Transitions From the Stroke Unit to the Home

NCT02925871 | Completed DMC

• 1 other identifier: 2015/1923-31/2
• Study Type: interventional
• Target: 49
• Locations: 1 country
• Sites: 2

Brief Summary

The aim is to design, implement and evaluate new person-centred transitions between stroke units and the home. The development of person-centred transition will be performed together by people with stroke, significant others, stroke unit staff and interdisciplinary teams. Phase 1, a prospective observational study of current transitions from stroke units to rehabilitation in the home without coordination. The aim is to identify factors that are facilitators or barriers to transitions, patient and caregiver outcomes, use of health care during the first year after stroke. In phase 2, a co-design process of new person-centred transitions will be carried out by people with stroke, significant others, stroke unit staff and interdisciplinary home rehabilitation teams. In phase 3 new person-centred transitions will be implemented and evaluated in a feasibility study.

Conditions

Stroke

Keywords

stroke; rehabilitation; interdisciplinary health team; patient-centered care; care transition

Outcome Measures

Primary Outcomes (1)

• Care Transition Measure

  Questionnaire that assesses perceived quality in care transitions. The total score (0-100) reflects the overall perceived quality of the care transition, with lower scores indicating a poor quality care transition, and higher scores indicating a higher quality care transition.

  1 week after discharge from hospital stroke unit

Secondary Outcomes (7)

• Health Literacy Questionnaire

  1 week and 3 months after inclusion

• Stroke Impact Scale, perceived recovery (patient)

  1 week and 3 months after inclusion

• The Medication Adherence Report Scale (patient)

  1 week and 3 months after inclusion

• General Self-Efficacy Scale (patient)

  3 months after inclusion

• Caregiver Burden Scale (significant other)

  3 months after inclusion

Other Outcomes (3)

• Fatigue visual analogue scale (patient)

  1 week and 3 months after inclusion

• Patient Health Questionnaire-2 (patient)

  1 week and 3 months after inclusion

• Barthel Index (patient)

  1 week and 3 months after inclusion

Study Arms (2)

Co-designed person-centred care transitions

EXPERIMENTAL

Co-designed person-centred care transitions from stroke unit to rehabilitation in the home

Behavioral: Co-designed person-centred care transitions

Current care transitions

ACTIVE COMPARATOR

Current care transitions from the stroke unit to rehabilitation in the home

Behavioral: Current care transitions

Interventions

Co-designed person-centred care transitions BEHAVIORAL

The intervention consists of several elements that aim to meet patients', significant others', and professionals' needs for shared understanding, patient preparedness for homecoming, and coordination.

Co-designed person-centred care transitions

Current care transitions BEHAVIORAL

Control group participants will receive current care transitions, initiated by an electronic referral from hospital healthcare professionals to the receiving neurorehabilitation team

Current care transitions

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• patients who have had a first time or recurrent stroke, and who will be discharged home from the participating stroke units and referred to a rehabilitation team in primary healthcare for continued rehabilitation in the home.

You may not qualify if:

• unable to give informed consent, due to e.g., severe aphasia or dementia.

Sponsors & Collaborators

• Karolinska Institutet: lead
• Swedish Council for Working Life and Social Research: collaborator
• Kamprad Family Foundation: collaborator

Study Sites (2)

Karolinska University Hospital

Huddinge, Sweden

Location

Danderyd hospital

Stockholm, 18288, Sweden

Location

Related Publications (10)

• Flink M, Lindblom S, Tistad M, Laska AC, Bertilsson BC, Warlinge C, Hasselstrom J, Elf M, von Koch L, Ytterberg C. Person-centred care transitions for people with stroke: study protocol for a feasibility evaluation of codesigned care transition support. BMJ Open. 2021 Dec 23;11(12):e047329. doi: 10.1136/bmjopen-2020-047329.

  PMID: 34949604 BACKGROUND

• Lindblom S, Ytterberg C, Elf M, Flink M. Perceptive Dialogue for Linking Stakeholders and Units During Care Transitions - A Qualitative Study of People with Stroke, Significant Others and Healthcare Professionals in Sweden. Int J Integr Care. 2020 Mar 25;20(1):11. doi: 10.5334/ijic.4689.

  PMID: 32256255 RESULT

• Lindblom S, Flink M, Sjostrand C, Laska AC, von Koch L, Ytterberg C. Perceived Quality of Care Transitions between Hospital and the Home in People with Stroke. J Am Med Dir Assoc. 2020 Dec;21(12):1885-1892. doi: 10.1016/j.jamda.2020.06.042. Epub 2020 Jul 29.

  PMID: 32739283 RESULT

• Lindblom S, Flink M, Elf M, Laska AC, von Koch L, Ytterberg C. The manifestation of participation within a co-design process involving patients, significant others and health-care professionals. Health Expect. 2021 Jun;24(3):905-916. doi: 10.1111/hex.13233. Epub 2021 Mar 17.

  PMID: 33729653 RESULT

• Lindblom S, Tistad M, Flink M, Laska AC, von Koch L, Ytterberg C. Referral-based transition to subsequent rehabilitation at home after stroke: one-year outcomes and use of healthcare services. BMC Health Serv Res. 2022 May 3;22(1):594. doi: 10.1186/s12913-022-08000-7.

  PMID: 35505404 RESULT

• Lindblom S, Ytterberg C, Flink M, Carlsson AC, Stenberg U, Tistad M, von Koch L, Laska AC. The Use of Teach Back at Hospital Discharge to Support Self-Management of Prescribed Medication for Secondary Prevention after Stroke-Findings from A Feasibility Study. Healthcare (Basel). 2023 Jan 30;11(3):391. doi: 10.3390/healthcare11030391.

  PMID: 36766966 RESULT

• Flink M, Lindblom S, von Koch L, Carlsson AC, Ytterberg C. Health literacy is associated with less depression symptoms, higher perceived recovery, higher perceived participation, and walking ability one year after stroke - a cross-sectional study. Top Stroke Rehabil. 2023 Dec;30(8):865-871. doi: 10.1080/10749357.2023.2178133. Epub 2023 Feb 21.

  PMID: 36803670 RESULT

• Hess Engstrom A, Flink M, Lindblom S, von Koch L, Ytterberg C. Association between general self-efficacy and health literacy among stroke survivors 1-year post-discharge: a cross-sectional study. Sci Rep. 2024 Mar 27;14(1):7308. doi: 10.1038/s41598-024-57738-z.

  PMID: 38538651 RESULT

• Lindblom S, Flink M, von Koch L, Laska AC, Ytterberg C. Feasibility, Fidelity and Acceptability of a Person-Centred Care Transition Support Intervention for Stroke Survivors: A Non-Randomised Controlled Study. Health Expect. 2024 Oct;27(5):e70057. doi: 10.1111/hex.70057.

  PMID: 39373138 RESULT

• Hess Engstrom A, Lindblom S, Flink M, Soderberg S, von Koch L, Ytterberg C. Stroke survivors' health literacy is not associated with caregiver burden: a cross-sectional study. Sci Rep. 2025 Feb 8;15(1):4720. doi: 10.1038/s41598-025-89523-x.

  PMID: 39922929 RESULT

MeSH Terms

Conditions

Stroke

Condition Hierarchy (Ancestors)

Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Vascular Diseases; Cardiovascular Diseases

Study Officials

• Charlotte Ytterberg, PhD

  Karolinska Institutet, Department of Neurobiology, Care Sciences and Society

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NON RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: associate professor (docent)

Study Record Dates

• First Submitted: April 8, 2016
• First Posted: October 6, 2016
• Study Start: April 1, 2016
• Primary Completion: December 7, 2022
• Study Completion: December 7, 2022
• Last Updated: March 27, 2026

Record last verified: 2026-03

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL, ICF, ANALYTIC CODE
• Time Frame: Immediately following publication and ending two years after publication
• Access Criteria: Since data can indirectly be traced back to the study participants, according to the Swedish and EU personal data sharing legislation, access can only be granted upon request. Request for access to the data can be put to our Research Data Office (rdo@ki.se) at Karolinska Institutet, and will be handled according to the relevant legislation. In most cases, this will require a data processing agreement or similar with the recipient of the data.

Locations

SE (2)