Postacute Stroke Care: Transitioning from Hospital to Home

Stroke is the second leading cause of death and disability worldwide. The Global Burden of Disease Study estimates that 143 million disability-adjusted life-years are attributable to stroke alone.¹ Because of persistent neurologic deficits, the consequences of stroke are felt by people who experience stroke and society long after the acute phase of care has passed. Many people who experience stroke have several comorbidities at time of discharge, often requiring multiple medications, additional diagnostic testing, and postdischarge follow-up. New physical or cognitive symptoms may impair individuals’ ability to adapt to these changes quickly on discharge home. For people discharged to rehabilitation or nursing facilities, faulty communication at time of discharge can lead to incorrect medication administration upon discharge or lack of follow-up on remaining tests to determine stroke etiology. This makes the transition from inpatient to outpatient care a critical time period that presents risk of readmission or additional morbidity and mortality without adequate follow-up care.

There is wide variety in the type and quality of care that people receive during this key transition. Several countries are exploring innovative models of care to support care transition and postacute care needs. However, there are often important limitations to providing these services, including barriers within health care and payer structures and the influence of social determinants of health in access to care and medications. Efficient, organized, and standardized transitional care can anticipate these barriers to appropriate treatment after discharge and provide support in this key point on the continuum of stroke care. Ongoing exploration of how best to serve people in the postacute stroke phase is needed to ensure optimal care.

Importance of Postacute Stroke Care and Barriers to Care

At the time of discharge, many people with stroke have new medical diagnoses, diagnostic tests pending, and new medications. In the Comprehensive Post-Acute Stroke Services (COMPASS) Study, 36.2% of people with stroke had high blood pressure at the time of discharge, 73.4% were on 5 or more medications, and approximately 70% did not have referrals for outpatient therapies.² Furthermore, 62% of these people with acute stroke did not have access to a primary care physician for close follow-up of newly diagnosed or inadequately controlled risk factors and multiple medications. This disparity is especially notable among minority populations in the United States, where blood pressure is more poorly controlled in Black Americans after acute lacunar stroke.³ The combination of new disability, new or complicated medication regimens, and lack of access to care places people at high risk of recurrent stroke, readmission, or poststroke complications, contributing to increased dependence and mortality at 3 months poststroke.⁴

Transitioning from inpatient to outpatient care is a critical step in stroke management. However, there can be significant variability in how individuals are treated at time of discharge from the inpatient setting. A 2017 study by Bettger et al.⁴ suggested that functional outcomes and mortality in the postacute period may depend not only on stroke severity but also on a discharging hospital’s characteristics, including hospital resources. For example, primary stroke centers and teaching hospitals have lower rates of morbidity and mortality, perhaps because of availability of resources for therapies and multidisciplinary teams to assist with transition home. Furthermore, discharge to acute inpatient rehabilitation versus subacute nursing facilities is variable, due to inconsistent availability of both high-level therapy and caregiver support, and potentially contributing to variability in poststroke disability.⁵

Discharge planning is not consistently well-organized across the globe despite being recommended by guidelines and standardization of discharge needs and follow-up is an area that requires further research.^6,7 An Australian study from 2018 assessed the overall quality of discharge planning for individuals admitted to the hospital after acute ischemic stroke.⁸ Measures included patient satisfaction with education regarding stroke and medications, placement, and readiness to return to community, and found that only 18% of individuals discharged felt that all aspects of care planning were met. Among those needing referrals for services and equipment, half did not receive hospital-guided support in accessing those resources. People with higher discharge quality scores were more likely to have been referred to support groups and provided information on hospital-based resources prior to discharge.⁸

Social determinants of health such as socioeconomic status (SES) and insurance status contribute to the barriers to appropriate postacute stroke care. In a 2011 study, Langagergaard et al.⁹ found that individuals with lower SES and unemployed job status had higher rates of mortality (hazard ratio 1.58) and readmission (hazard ratio 1.21) for cardiovascular events over 1 year following acute stroke compared with those with higher SES. Furthermore, in the Adherence Evaluation After Ischemic Stroke Longitudinal Registry, individuals with health insurance were 31% more likely to have medication adherence at 3 months postacute stroke.¹⁰ This trend was also seen in a 2007 study of barriers to medication adherence in 5840 stroke survivors in the United States.¹¹ Among those studied, those least likely to adhere to medication were Black Americans, women, and those with multiple comorbidities. Reasons for nonadherence included cost, lack of health insurance, lack of transportation to pharmacy, and lack of established primary care.¹¹ Given these findings, improved support in the postacute stroke period for those with low SES or without health insurance is a potential area for targeted intervention to mitigate these disparities in care.

Models

Several healthcare models have been developed to facilitate transition from the hospital setting after acute stroke. Early supported discharge (ESD) is a model first implemented primarily in Western Europe and Canada, with subsequent expansion globally.¹² The aim of this model is to accelerate transition home following stroke with the support of rehabilitation services in the home. Advantages to ESD include shorter hospital stay and early engagement of therapies and targeting of potential functional disabilities. These programs engage multidisciplinary teams to coordinate follow-up and implementation of outpatient therapies. A Cochrane review showed that ESD resulted in reductions in length of hospital stay of up to 6 days and decreased death or dependency at the end of scheduled follow-up (odds ratio 0.80; 95% CI 0.67-0.95; P=.01), with better results in trials evaluating a coordinated, multidisciplinary ESD team. Overall cost to implement ESD varied. In 6 individual trials, cost ranged from 23% lower to 15% greater for ESD compared with conventional services, but satisfaction improved with the interventions.¹²

The COMPASS Study evaluated a care model similar to ESD in the United States.¹³ The intervention involved a multidimensional approach to address therapy and medical needs as well as systemic structures affecting people with stroke upon discharge. Individuals were identified and provided education during hospital admission and received telephone follow-up at 2, 30, and 60 days after discharge to address medications and new symptoms and to ensure appropriate follow-up. A 14-day stroke clinic appointment was conducted by an advanced practice provider with patient and caregiver assessments delivered to develop an individualized care plan addressing stroke education, prevention, rehabilitation, and recovery. Patients were referred to appropriate community resources as needed throughout the study to evaluate the effects of increased support during this transition of care. Results of this trial were mixed and full implementation was limited at many sites due to lack of the necessary resources. There was no difference in functional outcomes at 90 days compared with traditional poststroke care, but blood pressure monitoring increased in the intervention group, which is potentially significant to management of risk factors in this critical poststroke period. The limitations of this study highlight the difficulty of implementing a model of supported care when the resources required to support individuals are at odds with traditional care delivery through the existing medical system.¹⁴

An emerging pathway for transient ischemic attack (TIA) and minor stroke is one that attempts discharge from the emergency department based on availability of rapid access clinics and ability to obtain diagnostic tests either in the emergency department or outpatient. The Effect of Urgent Treatment of Transient Ischemic Attack and Minor Stroke on Early Recurrent Stroke (EXPRESS) Study based in the United Kingdom implemented a rapid access clinic for people with TIA presenting to the emergency department to obtain outpatient brain imaging, electrocardiogram, and carotid ultrasound instead of hospital admission. Appropriate antiplatelet and antihypertensive regimens were initiated at time of presentation. There was an overall reduction in rates of stroke following this intervention.^15,16 Similarly, in the United States, collaborations with the emergency department to utilize an observation unit for TIA and mild stroke evaluation and for rapid evaluation and discharge within 24 hours has been shown to reduce costs, improve patient satisfaction, and allow individuals to return to their communities more quickly without significant differences in rates of future stroke compared with usual care.¹⁷ Careful selection of individuals appropriate for this pathway is important and no strong consensus on patient selection has been reached by society guidelines.¹⁷

Opportunities and Future Directions

Methods for improving transition of care to outpatient settings for people with stroke are continually evolving. Thoughtful coordination of care prior to discharge is essential during this critical period and has the potential to improve morbidity and mortality. Development of systems of transitional care may also have broader effects on the health care system, including decreased length of stay, improved patient satisfaction, and decreased cost compared with traditional models of care.

Considering the evidence, transitional care services should be developed with an eye toward overcoming barriers to care. Services should focus on supporting individuals through recovery and rehabilitation of new disability, coordinating medications and services for newly identified diagnoses, and ensuring continued access to care and medications after discharge (Figure 1).

One opportunity to address barriers to care during this transition is through the utilization of telemedicine for delivery of postacute services. Telerehabilitation has shown equivalent functional outcomes and gains in activities of daily living when compared with in-person therapy.^18,19 Telemedicine addresses many unique barriers to care following acute stroke, including new mobility limitations, reliance on caregivers, and lack of regional access to subspecialty care. Inconsistency in availability of stroke-specific rehabilitation services contributes to poor outcomes after acute stroke and remote delivery of these services has the potential to reduce or eliminate this disparity in care. For ambulatory care, telemedicine has shown similar diagnostic accuracy and patient satisfaction across multiple neurologic subspecialties.²⁰ In regions with poor access to stroke care, telestroke has revolutionized the availability of acute stroke care, including thrombolytics and thrombectomy. Similarly, ambulatory neurology follow-up via telemedicine could provide postacute stroke care in regions with poor access and has the potential to provide consistency and standardization in postacute care.

Specific considerations are required to address the impact of social determinants of health on poststroke care. Low SES and lack of health insurance are correlated with decreased medication adherence and increased morbidity and mortality and future solutions must address these barriers to care in order to improve secondary stroke prevention and long-term morbidity. Systems of care and funding agencies should focus on these needs not only to improve health care but also to reduce the health care burden and societal impact of long-term disability in this population.

Conclusion

The past decade has resulted in many advances in the acute care of individuals with stroke. Equally important to people who experience stroke is the postacute period of rehabilitation and recovery and secondary stroke prevention. However, during the transition from hospital to home, there are several ways that patient care may be disrupted. A large proportion of individuals lacks established primary care or access to appropriate rehabilitation services, both critical needs in a time of new disability, new diagnoses, and new medications. Ensuring continuity of care and appropriate support for individuals as they return home is key for community reintegration and is the target for ESD and other multidisciplinary interventions. Multidisciplinary care should be coordinated to individual patient and caregiver needs before discharge to ensure optimal follow-up, either in person or via telemedicine in regions where specialty access is limited. Standardization of stroke discharge needs and consideration of barriers to accessing care are critical to addressing this variability after hospitalization and improving functional outcome after stroke.