NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Olson DWM, Bettger JP, Alexander KP, et al. Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Oct. (Evidence Reports/Technology Assessments, No. 202.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Transition of Care for Acute Stroke and Myocardial Infarction Patients

Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention.

Show details

Summary and Discussion

For this report, we conducted a systematic review of the indexed medical literature to evaluate the evidence for transition of care services and programs that improve the post hospitalization quality of care for patients who have undergone strokes or MIs. A challenge in preparing this review was in defining the concept of “transition of care” following hospitalization with stroke or MI. We focused on the process that a patient underwent as they left the acute-care hospital and reintegrated into society. For some patients, that process involved a transient stay in an acute rehabilitation setting followed by discharge to home, while for others the transition involved relocation to a skilled nursing home or assisted living environment. We found Coleman’s definition of transition of care most appropriate for our purposes: “the set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.”1

The conceptual model we worked with was one that began with hospital-initiated support for discharge to home or to intermediary care units and subsequently involved community-based resources such as multidisciplinary care teams, group support services, and patient-and family -focused educational programs. The process of hospital-initiated discharge preparation often included education of the patient and/or their family or health care providers as well as initiating followup care with primary and specialty care providers. Community-based support services were often initiated at this time as well. Educational programs based in the community were also evaluated, as were community-based systems of support. Although the majority of patients with stroke or MI also had a number of concurrent chronic medical conditions such as diabetes, hypertension, and hyperlipidemia that had contributed to the sentinel presenting event (stroke or MI), we did not incorporate chronic disease management models as a component of transition of care.

In this review, we found that the process of transitioning the care of a patient from the hospital to the community began in the hospital as part of the discharge planning process (intervention type 1). This phase included interventions such predetermined integrated-care pathways, early supported discharge, extended stroke unit services, and rehabilitation coordination with community services. Education of the patient and family prior discharge was also initiated during the acute hospitalization (intervention type 2). Educational programs varied from those that provided information packages to direct teaching by subspecialty trained nurses.

Following hospital discharge, community-based support of the patient and family (intervention type 3) could be provided through advanced practice nurse care managers, primary care and specialty-based medical practitioners, and multidisciplinary care teams (including doctors; nurses; social workers; and physical, occupational, and speech therapists). This support could be provided in person at the patient’s home, by telephone, or at a clinical practice setting (physician’s office, outpatient rehabilitation setting or common meeting place for support groups). Ongoing patient and family education could also be maintained at the community level, such as the provision of medical-focused manuals, rehabilitation and lifestyle information, videotapes, and telephone-based educational programs.

Chronic disease management (intervention type 4) was reviewed as part of the process of transition of care, and a few disease management models were identified that included the outcomes of interest in our review: one MI and three stroke intervention programs.

De spite a conceptual basis to support the transition of care, we found limited evidence in favor of some components of hospital-initiated discharge planning (transition of care after stroke and specialty followup after MI). Transition of care interventions seemed able to reduce the total number of hospitalized days without adversely impacting long term functional recovery or death. Specialty care followup after MI was associated with reduced mortality. There were no transition of care interventions that consistently improved functional recovery after stroke or MI, and none seemed to consistently improve quality of life or psychosocial factors such as strain of care, anxiety, or depression.

Limitations of This Review

Across the 62 articles (44 studies) that met the inclusion criteria for this review, the major limitations were inadequate sample size, heterogeneity of outcome measures, lack of definition for the usual care group, and numerous studies conducted outside of U.S. settings. Few studies were designed with a single primary endpoint, but rather simultaneously reported multiple outcome measures, frequently with an inadequate sample size to justify multiple statistical comparisons. The reported outcome measures included both validated and unvalidated outcome scales as well as combinations of the two. The treatment interventions were not always clearly described. Some studies included more than one intervention, which made it difficult to determine the effect of individual components on clinical outcomes.

The interventions reported did not include postdischarge medication management. Poor medication management is one of the recognized reasons for hospital readmissions in chronic care. There were no studies that addressed racial, ethnic, or cultural factors that could influence access or response to transitional care.

The most limiting aspect of the studies reviewed was that they did not define what constituted the control intervention, which in many cases was simply referred to as “usual care.” The latter made cross-study comparisons challenging. This heterogeneity in the intervention and control treatments precluded conducting a meta -analysis of the cohort of studies. A significant number of these studies (some of the better ones) were conducted outside the U.S. in countries with significantly different health care systems than ours (frequently in countries with single-payer systems), thus making translation of their results more challenging.


This systematic review showed limited evidence for making definitive conclusions about the effectiveness of transition of care services following stroke or MI. Although we were able to define a conceptual framework and a specific taxonomy for transition of care services that served as the foundation for evaluating the published literature, the evidence for efficacy in the setting of stroke and MI was insufficient. A number of studies that we reviewed were based on a solid conceptual framework with reasonable study designs but had too few patients to be able to reach statistically valid conclusions. Other studies did not follow their subjects long enough, and too many studies used inconsistent endpoints to be able to make comparisons. Although acute MI and stroke share many risk factors, the scope of medical needs for each of these two populations is quite different. Even though we attempted to evaluate the individual components of transition of care services for each disease entity, we found that each medical condition presented unique care issues that required specific transition of care interventions. This was most true for the utilization of rehabilitation services following stroke.

As the population of the U.S. gets older and the number of patients experiencing MI or stroke increases, it will be imperative to have transition of care interventions that have proven to be effective in improving functional outcomes, facilitating transfer of care from a hospital-based system to a community-based medical system while at the same time effectively utilizing health care resources to maintain health. Based on the findings of this review, few studies support the adoption of any specific transition of care program as a matter of health care policy. Some components, such as early supported discharge following stroke, appear to shorten length of stay and improve short-term disease. A similar approach following MI with early return to work also seems to be safe and cost-effective. Additional well-structured research performed in the U.S. is necessary before concluding that a specific approach is effective and worthy of widespread adoption. These studies will need to be disease focused because stroke and MI involve quite different populations with unique challenges to overcome.

Table 19 summarizes the findings for each key question.

Table 19. Summary of findings.

Table 19

Summary of findings.


  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (1.2M)
  • Disable Glossary Links

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...