Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, Sweden; Department of Health Sciences, Lund University, Sweden.
Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Sweden.
J Rehabil Med. 2024 Jun 20;56:jrm35240. doi: 10.2340/jrm.v56.35240.
To explore how people with stroke, discharged to skilled nursing facilities before returning home, experience the chain of care and rehabilitation.
Qualitative, semi-structured interview design.
Thirteen stroke survivors discharged from a stroke unit to a skilled nursing facility before returning to independent living participated. Semi-structured telephone interviews were conducted 2-5 months after stroke and analysed with content analysis.
The analysis resulted in three categories, Organizational processes, critical and complex, Rehabilitation, the right support at the right time and Adaptation to the changed situation, with a total of 9 subcategories. The informants perceived low participation in planning and goalsetting and limited information. Support from the healthcare services was important to proceed with improvements although the amount of supported training varied. Factors hindering and facilitating managing everyday life were described, as well as lingering uncertainty of what the future would be like.
Support and rehabilitation as well as individuals' needs varied, throughout the chain of care. To enable participation in the rehabilitation, assistance in setting goals and repeated information is warranted. Tailored care and rehabilitation throughout the chain of care should be provided, followed up at home, and coordinated for smooth transitions between organizations.
探讨出院至康复护理院、继而返回家庭的脑卒中患者在接受连续治疗和康复过程中的体验。
定性、半结构式访谈设计。
13 名脑卒中幸存者在出院至康复护理院后参与了研究，他们在脑卒中发作后 2-5 个月接受了半结构式电话访谈，并进行了内容分析。
分析结果得出三个类别，分别是组织流程、关键和复杂、康复、在适当的时间获得适当的支持以及适应变化的情况，共计 9 个子类别。受访者认为在规划和目标设定方面参与度低，且信息有限。尽管支持的培训量有所不同，但来自医疗保健服务的支持对于取得进展很重要。描述了阻碍和促进日常生活管理的因素，以及对未来的不确定性。
在整个治疗过程中，支持和康复以及个人的需求各不相同。为了使患者能够参与康复，需要提供设定目标和重复信息方面的帮助。应该在整个治疗过程中提供个性化的护理和康复，在家庭中进行随访，并协调组织之间的顺利过渡。
