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Background Older adults with stroke and multimorbidity experience frequent care transitions, which are often poorly coordinated and fragmented. We conducted a pragmatic randomized controlled trial (RCT) to test the implementation and effectiveness of the Transitional Care Stroke Intervention (TCSI), a 6-month, multi-component, evidence-informed intervention to support older adults with stroke and multimorbidity using outpatient stroke rehabilitation services. The TCSI was designed to support self-management, improve health outcomes, and enhance the quality and experience of care transitions. Objective To explore the facilitators and challenges to implementing the TCSI, from the perspective of healthcare providers (HCPs) (n = 12) and Managers (n = 3). Methods Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Data were collected from study documents, individual and group interviews conducted with HCPs and a Care Coordinator, and surveys from managers. Data were analyzed using thematic analysis. Results Intervention implementation was facilitated by: a) strong collaborative and interdependent HCP team relationships, b) dedicated resources (funding, staffing) to support intervention delivery, c) training and ongoing support, customized to individual HCP needs, d) organizational readiness, strong leadership, and effective champions, e) structures to facilitate virtual information-sharing, and f) regular monitoring of intervention implementation. Implementation challenges included: a) COVID-19 related challenges (staff turnover, community service disruptions), b) poor communication with community service providers, c) documentation burden (intervention-related), and d) virtual care delivery. Conclusions This research enhances understanding of the diversity of factors influencing implementation of the TCSI, and the conditions under which implementation is more likely to succeed.

Abstract Background This study aimed to test, in real-world clinical practice, the effectiveness of a Transitional Care Stroke Intervention (TCSI) compared to usual care on health outcomes, self-management, patient experience, and health and social service use costs in older adults (≥ 55 years) with stroke and multimorbidity (≥ 2 chronic conditions). Methods This pragmatic randomized controlled trial (RCT) included older adults discharged from hospital to community with stroke and multimorbidity using outpatient stroke rehabilitation services in two communities in Ontario, Canada. Participants were randomized 1:1 to usual care (control group) or usual care plus the 6-month TCSI (intervention group). The TCSI was delivered virtually by an interprofessional (IP) team, and included care coordination/system navigation support, phone/video visits, monthly IP team conferences, and an online resource to support system navigation. The primary outcome was risk of hospital readmission (all cause) after six-months. Secondary outcomes included physical and mental functioning, stroke self-management, patient experience, and health and social service use costs. The intention-to-treat principle was used to conduct the primary and secondary analyses. Results Ninety participants were enrolled (44 intervention, 46 control); 11 (12%) participants were lost to follow-up, leaving 79 (39 intervention, 40 control). No significant between-group differences were seen for baseline to six-month risk of hospital readmission. Differences favouring the intervention group were seen in the following secondary outcomes: physical functioning (SF-12 PCS mean difference: 5.10; 95% CI: 1.58–8.62, p = 0.005), stroke self-management (Southampton Stroke Self-Management Questionnaire mean difference: 6.00; 95% CI: 0.51—11.50, p = 0.03), and patient experience (Person-Centred Coordinated Care Experiences Questionnaire mean difference: 2.64, 95% CI: 0.81, 4.47, p = 0.005). No between-group differences were found in total healthcare costs or other secondary outcomes. Conclusions Although participation in the TCSI did not impact hospital readmissions, there were improvements in physical functioning, stroke self-management and patient experience in older adults with stroke and multimorbidity without increasing total healthcare costs. Challenges associated with the COVID-19 pandemic, including the shift from in-person to virtual delivery, and re-deployment of interventionists could have influenced the results. A larger pragmatic RCT is needed to determine intervention effectiveness in diverse geographic settings and ethno-cultural populations and examine intervention scalability. Trial registration ClinicalTrials.gov Identifier: NCT04278794 . Registered May 2, 2020.