Effectiveness of an integrated care program for intensive home care services after discharge of stroke patients

Abstract

The continuity of care in hospital discharge is a cornerstone of patient-centred care, particularly after an acute episode with a high impact on patients’ autonomy. In the setting of stroke, a highly disabling disease, early delivery of post-discharge support services has been associated with better health outcomes. However, the lack of integration between social and health care services often delays the start of home care services in these patients, likely worsening health outcomes. In our area, a post-stroke intensive home care program (RHP) was launched to integrate social and health care services for improving the domiciliary care of stroke patients after hospital discharge.