Implementation of a formalized transitional stroke care model optimizes success for both the patient with stroke and the comprehensive stroke center of care, though transitional care after hospital discharge remains highly variable.
The COMPASS-TC randomized clinical trial testing an early-supported discharge program was significantly limited by poor uptake.
The Joint Stroke Transitional Technology-Enhanced Program demonstrated high value with visit completion rates greater than 80% with the stroke specialist.
Numerous single-center reports have demonstrated benefits for hospitalized patients with stroke when postdischarge transitional care is well coordinated.
The ideal transitional stroke care framework is driven by protocolized care delivery models aimed at efficient diagnostic processes, adherence to effective treatments, and avoidance of common poststroke complications.
This research suggests that while structured care during a stroke hospitalization has improved survival and recovery outcomes, the care patients receive after they leave the hospital varies widely and lacks standardization. The article reviews what is currently known about 'transitional stroke care' — the support and follow-up provided to stroke patients as they move from the hospital back into the community — and examines which approaches seem to work best. One key finding is that a large national study testing a structured early discharge support program (called COMPASS-TC) struggled because most enrolled patients never actually completed the program's visits — only 35% did. In contrast, a telemedicine-based program called the Joint Stroke Transitional Technology-Enhanced Program showed much better results, with over 80% of patients completing their visits with a stroke specialist, faster access to recovery resources, and lower rates of being readmitted to the hospital within 30 days compared to national averages. This research suggests that how a transitional care program is designed and delivered matters enormously — simply having a program available is not enough if patients cannot or do not engage with it. Telemedicine-based, interprofessional approaches may be particularly effective at keeping patients connected to their care after hospital discharge. The findings highlight an important gap in stroke recovery and point toward specific program features, like technology-enabled visits and coordinated specialty care, that may help bridge that gap.
Bahouth M. (2026). Transitional Stroke Care and the Road to Recovery.. Continuum (Minneapolis, Minn.). https://doi.org/10.1212/cont.0000000000001706