The proportion of people living with stroke is growing. In England, National Institute for Health and Care Excellence (NICE) Guidelines for stroke recommend that a person with suspected or confirmed stroke event is admitted to a specialist stroke unit, in order to receive required treatment promptly. Stroke rehabilitation follows, which involves providing stroke survivors with support and treatment from a multidisciplinary rehabilitation team. Stroke survivors’ transition from acute settings to rehabilitation can take place either in hospital, at home or the community.
One model of care is Early Supported Discharge (ESD), which offers community-based health and social care as an alternative to inpatient care. NICE recommend that transfers of care from hospital to community should include all pertinent health and social care information, given to relevant health and social care professionals and patients promptly.Long-term care led by generalists in the community is recommended and stroke survivors are encouraged to self-refer if any issues arise. However, it is unclear whether primary care models of care are effective for addressing stroke survivors’ and carers’ unmet needs, and challenges to implementing integrated care remain. For instance, ESD was only offered to 34.6% of eligible patients in a 2017 National Audit. Cochrane reviews show that ESD for stroke does reduce hospital lengths of stay, but taken as a whole, early discharge services for adults (including stroke) have no effect on mortality.
Integrated care models, where distinct but related structures such as health and social care providers and organisations interact, are increasingly common. However, beyond ESD, integrated care for stroke remains underdeveloped both in the UK and internationally, and patients and carers have described follow-up care as fragmented. Integrated stroke care services require good information exchange between healthcare professionals after discharge, as part of addressing survivors’ and carers’ needs for continued support.
As part of a larger research programme to develop a new model of primary care for stroke survivors living in the community, this study aimed to explore generalist-specialist communication concerning long-term stroke care following hospital discharge, specifically: (1) What are the communication processes between generalists and specialists concerning stroke care after hospital discharge? (2) What are the barriers and enablers to communication between these groups?