Effects of an integrated transitional care program for stroke survivors living in a rural community: a randomized controlled trial.

Objective: To evaluate the effect of an integrated transitional care program on health outcomes in stroke survivors based on an original community for healthcare.

Design: A pilot randomized controlled trial with blinded assessment. Randomization by statistician using computer-generated, random numbers concealed in opaque envelopes.

Setting: A tertiary hospital and participants' home across Lishui, China.

Subjects: A total of 98 people with acute cerebral hemorrhage or cerebral infarction, eight weeks following discharge from our hospital.

Interventions: Each participant received stroke unit-based treatment including acute medical treatment, early rehabilitation and health education. Patients in the intervention group received ongoing rehabilitation at home through multidisciplinary team, while patients in the control group received secondary stroke prevention.

Main Measures: Short-Form Health Survey-36, Modified Barthel Index and Caregiver Strain Index at four and eight weeks, respectively, after discharged.

Results: A total of 98 participants were recruited (intervention = 49, control = 49). Patients had an average age of 61.4 years (61.4 ± 18.3). Mean values of Physical Components Summary and Mental Components Summary, integral components of Short-Form Health Survey-36, were significantly better in the intervention group at four and eight weeks (40.2 ± 6.3 and 42.9 ± 3.7 for the former; 43.9 ± 2.6 and 46.1 ± 1.8 for the later). The same trend was observed in Modified Barthel Index (87.1 ± 9.2 and 92.5 ± 6.7 at four and eight weeks, respectively). But the significant improvement in Caregiver Strain Index was only observed at four weeks. There were significant differences between groups in these scores.

Conclusion: The transitional care program has been proven to be feasible and improve health-related outcomes.