Transitional care interventions and outcome measures in stroke rehabilitation: a scoping review.
Carla Tierney-Hendricks, Alyssa Garza, Liam Keefe and 5 others
Most stroke transitional care programs center on educating patients and families, while system-level supports like care coordination are rarely built in.
Only 3 of 31 measured language or communication outcomes, and 17 restricted or 4 excluded people with aphasia or cognitive-communication disorders.
Key findings
1Individual-level components dominated: patient education appeared in 29 of 31 programs, caregiver education in 21, needs screening in 19, and self-management training in 18. System-level components were less common: access to rehabilitation services in 19, progress monitoring in 18, and information transfer between providers in 18. Care coordination with a patient navigator appeared in only 4 of 31 programs, on-call provider lines in 5 of 31, and structured discharge planning tools in 6 of 31.
2Cognitive-communication needs were largely unaddressed. Only 4 of 31 interventions explicitly included people with aphasia or cognitive-communication disorders, 17 had restrictive inclusion of this group, 4 explicitly excluded them, and 4 did not describe their cognitive-communication status. Only 3 of 31 programs measured language or communication ability as an outcome, and 9 measured cognitive functioning.
3The 31 interventions ranged from 3 components to 21 components, and most were multi-level, combining individual- and system-level strategies. The most common transition addressed was acute care to home (13 programs), followed by inpatient rehabilitation to home (7) and transitions across multiple settings (9).
Still to come
How it was doneWhat they foundWhat it means for PTsWhat it means for OTsWhat it means for SLPs
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What it does not show
English-language, peer-reviewed studies only, which may underrepresent the full range of transitional care interventions in stroke rehabilitation. Restricted to publications from 2012 onward, potentially excluding earlier foundational work that still informs practice. The diversity of intervention designs, dosages, and outcome measures meant the authors could not draw conclusions about efficacy across studies. Lack of specificity in how individual studies reported their interventions limited the ability to link specific components to specific outcomes. The protocol was not registered before the review was conducted.
Declared interests
No potential conflict of interest was reported by the authors.
The easy way to misread this
This is a map of what exists in the literature, not a test of what works. The authors state they could not draw conclusions about efficacy across studies because of the diversity of designs and measures. The finding that most programs focus on patient education is a description of the current landscape, not a recommendation that education is the right or sufficient approach. The authors themselves argue that the over-reliance on individual-level components is a gap, not a strength.
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