Care transition and network activation within home supported discharge service for stroke patients in Portugal

Introduction: Strong evidence exists that there are serious quality problems for patients undergoing transitions across sites of care (1). This is a particularly acute and problematic issue at a time when care systems face the challenges brought about by increasingly elder populations (2), translated in rising levels of co-morbidities, chronicity, degenerative illnesses and disabilities, with escalating provision costs, and try to reconfigure the delivery of care services with strong emphasis on deinstitutionalization and community-based support. In Portugal, a number of top down regulated initiatives aiming at implementing integrated care in the country have been attempted in the last years but the care system still presents a remarkable diversity of entry points, inadequate many times duplicated use of scarce and expensive resources and difficult information flow between institutions and professionals. Coordination between health and social care including home-based care settings most of the times depends on the good will of dedicated professionals and the individual is many times left alone to navigate through the fragmented systems and the several care providers he might encounter in the path to rehabilitation. The main goal of this paper is to report on the quality of care transitions including actions intended to activate networks of care from the perspective of the patient, in the context of a randomized control trial on home supported discharge service for stroke patients in Portugal.