A non-randomised controlled study of the missing link person-centred care transition support intervention after stroke or TIA

The transition from hospital to home after stroke or transient ischaemic attack (TIA) is a vulnerable phase marked by gaps in coordination, communication and patient preparedness. This study evaluated the effectiveness of a multicomponent care transition support on perceived quality of care transition (QCT) amongst people with stroke or TIA one week post-discharge. This non-randomised controlled study was conducted in three Swedish hospitals. Adult people with stroke or TIA discharged to home and referred for home-based neurorehabilitation were eligible. Data were collected during hospitalisation and at a blinded one-week follow-up. Primary outcome was perceived QCT, assessed with the Care Transition Measure. Secondary outcomes included health literacy, medication adherence and perception of received care. In total, 163 participants completed follow-up. The intervention group reported higher perceived QCT than controls (p = 0.002), which remained significant after adjustments (β = 6.34; 95% CI 0.56–12.12; p = 0.03). The intervention group reported greater confidence in managing health and better understanding of medications. Health literacy was higher in the intervention group, with no between-group differences in medication adherence or perception of received care. A multicomponent care transition support intervention may improve perceived QCT early after discharge in people with stroke or TIA.