Long-term effects of the intensification of the transition between inpatient neurological rehabilitation and home care of stroke patients

OBJECTIVE: To investigate an intensified transition concept between neurological inpatient rehabilitation and home care for long-term effects on the care situation two and a half years after stroke patients' discharge. DESIGN: Controlled clinical trial allocating patients to intervention group (intensified transition on ward II) or control group (standard transition on ward I); patients were allocated to whichever ward had a vacancy. The last follow-up assessment was carried out on average 31 months after discharge. INTERVENTION: The intensified transition concept consisted of therapeutic weekend care, bedside teaching and structured information for relatives during the second phase of the rehabilitation. SUBJECTS: Seventy-one patients and their family carers were included, of which one case dropped out. Therefore 70 family carers--35 individuals in each group-- were available for assessment at long-term follow-up. DATA COLLECTION: Family carers were asked via telephone whether the patient was still alive and if so, where he or she is living--at home or in a nursing home. Statistical methods: Binary logistic regression analysis with the care situation (home care versus institutionalized care or deceased) as dependent variable. RESULTS: Two and a half years after discharge (T3) in the intervention group significantly fewer patients were institutionalized (2 versus 5) or deceased (4 versus 11) (P = 0.010). Multivariate analysis showed that besides a higher functional life quality at discharge and lower patient's age, the participation in the intensified transition programme is the third significant predictor for home care at T3. CONCLUSION: Effects of an intensified transition programme can persist over a long-term period. They can sustain home care by reducing institutionalization and mortality.