What is it about?

Stroke early supported discharge (ESD) involves the co-ordinated transfer of care from hospital to home. We explored how communication processes between professionals delivering ESD , stroke survivors and other services in the stroke care pathway influence the hospital-to-home transition and delivery quality of ESD. We interviewed 117 staff members, including clinical staff, service managers and commissioners from six ESD services in England.

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Why is it important?

Findings stress the role of effective communication and information exchange processes in developing collaborative and trusting relationships and streamlining care transitions. Cross-boundary working arrangements with inpatient services helped clarify the role and remit of ESD, contributing to timely hospital discharge and response from ESD teams. Staff perceived honest and individualised information provision as key to effectively prepare stroke survivors and families for the hospital-to-home transition and for promoting rehabilitation engagement. In designing and implementing ESD, early stakeholder involvement ensured the services’ fit in the local pathway and good communication going forward.


I believe this study highlights the interdependency between services aiming to accelerate patients' discharge from hospital and local stroke care pathways. Maintaining good communication and engagement with key stakeholders may facilitate a timely hospital discharge process. ESD services should actively manage communication processes and invest in maintaining ongoing engagement with service users and other services . A shared cross-service communication strategy to guide the provision of information along to continuum of stroke care may help streamline care transitions while maintaining the continuity of care.

Niki Chouliara
University of Nottingham

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This page is a summary of: Getting the message across; a realist study of the role of communication and information exchange processes in delivering stroke Early Supported Discharge services in England, PLoS ONE, March 2024, PLOS,
DOI: 10.1371/journal.pone.0298140.
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