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Conference Abstracts

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

Authors:

Maureen Markle-Reid ,

McMaster University, Canada, CA
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Mark Bayley,

Toronto Rehabilitiation Institute University of Toronto, CA
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Marla Beauchamp,

McMaster University, Canada, CA
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Jill Cameron,

University of Toronto, CA
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David Dayler,

McMaster University, Canada, CA
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Jeane Davis-Fyfe,

Hotel Dieu Shaver Health and Rehabilitation Centre, CA
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Rebecca Fleck,

Hamilton Health Sciences, CA
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Amiram Gafni,

McMaster University, Canada, CA
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Rebecca Ganann,

McMaster University, Canada, CA
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Ken Hajas,

McMaster University, Canada, CA
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Anne Hayes,

Ontario Health, CA
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Barbara Koetsier,

McMaster University, Canada, CA
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Robert Mahony,

McMaster University, Canada, CA
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Michelle Nelson,

Toronto Rehabilitiation Institute Sinai Health System, CA
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Jim Prescott,

McMaster University, Canada, CA
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Chris Pollard,

Hotel Dieu Shaver Health and Rehabilitation Centre, CA
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Jennifer Salerno,

McMaster University, Canada, CA
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Lahana Thabane,

McMaster University, Canada, CA
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Carly Whitmore

McMaster University, Canada, CA
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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 partners. The TCSI is a complex intervention that includes early post-discharge follow-up, system navigation support and care coordination, up to 6 virtual home visits by the IP team, monthly IP case conferences, self-management and community re-integration support, secondary stroke prevention and health promotion education, and linkages to local health (primary care, outpatient rehabilitation, community services) and social care.

Objectives: To describe the perceived impacts, facilitators, and barriers to the implementation of the TCSI from the perspectives of healthcare providers (comprised of Occupational Therapist, Physiotherapist, Registered Nurse, Social Worker, Speech Language Pathologist), and Managers.

Methods: A qualitative descriptive study design was used. Healthcare providers involved in delivering the TCSI from two study sites in Ontario, Canada were included. Data collection consisted of 6 interviews with managers, 4 focus groups with a total of 10 providers, and study-related documentation. A directed content analysis approach informed by the Consolidated Framework for Implementation Research was used.

Preliminary Findings and Impact: Providers perceived that the intervention enhanced IP teamwork, continuity, and coordination of care, increased their understanding of community resources and assessment tools, addressed barriers to quality transitional care, and improved integration of outpatient stroke rehabilitation with community-based health and social services (primary, home and community care). Implementation facilitators included having a dedicated Care Coordinator, using a team-based approach to provide person-centred care for stroke rehabilitation, use of a common platform for documentation, and organizational leadership support. Implementation barriers included turnover of IP team members, virtual patient data exchange that met security and privacy standards, inability to provide hands-on assessment or treatment, e.g., exercises, and lack of patient access to technology or digital literacy.

Conclusions: The TCSI can be integrated into real-world practice to foster integrated stroke care and improve the quality of transitions from hospital to home for older adults with stroke and multimorbidity.

Implications for transferability, sustainability, and limitations: The TCSI intervention has the potential to address gaps in post acute stroke care and enhance the quality of transitions from hospital to home. Despite positive findings, evidence for intervention effectiveness is needed to inform scale-up of the intervention more broadly

 

 

 

How to Cite: Markle-Reid M, Bayley M, Beauchamp M, Cameron J, Dayler D, Davis-Fyfe J, et al.. Perceived Impacts, Facilitators and Barriers to Optimize Hospital-to-Home Transitions for Older adults with Stroke and Multimorbidity through a Virtual Transitional Care Intervention. International Journal of Integrated Care. 2022;22(S3):272. DOI: http://doi.org/10.5334/ijic.ICIC22137
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Published on 04 Nov 2022.

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