Background Home-based exercise rehabilitation plays a vital role in enhancing functional recovery among stroke patients; however, adherence remains low because of limited continuity of care, inadequate professional supervision, and discontinuities in the transition from home to community settings. Although previous studies have examined home-based rehabilitation experiences, they lack systematic integration from the perspective of care continuity, which hinders the development of a collaborative intervention framework across different care settings. Purpose This study synthesizes the real-world experiences of stroke patients transitioning from hospital to home rehabilitation. It aims to elucidate how care continuity influences rehabilitation behaviors and to provide insights for optimizing nursing strategies. Method A comprehensive search of six major databases (including PubMed, Embase, and CINAHL) was conducted. Ten qualitative studies were identified, appraised, and synthesized following the Joanna Briggs Institute (JBI) framework. Result The synthesis included 263 stroke patients. Four major categories were identified: (1) deficiencies in discharge guidance and follow-up; (2) challenges in self-regulation and home-based motivation; (3) the facilitating role of family and community support; and (4) the influence of nursing and family support continuity. Existing services exhibit marked transitional discontinuities. Conclusion The home rehabilitation experience is shaped by the interplay among care continuity, self-regulation, and support networks. We propose a closed-loop model encompassing guidance, monitoring, and motivation. This framework provides a practical approach to optimizing the hospital-community-home collaborative system, thereby promoting sustained adherence and improving long-term recovery outcomes. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD42023405581 , PROSPERO CRD42023405581.
Xu et al. (Wed,) studied this question.