Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive study

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),...

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Main Authors: Maureen Markle-Reid, Kathryn Fisher, Kimberly M. Walker, Jill I. Cameron, David Dayler, Rebecca Fleck, Amiram Gafni, Rebecca Ganann, Ken Hajas, Barbara Koetsier, Robert Mahony, Chris Pollard, Jim Prescott, Tammy Rooke, Carly Whitmore
Format: Article
Language:English
Published: SAGE Publishing 2025-02-01
Series:Journal of Multimorbidity and Comorbidity
Online Access:https://doi.org/10.1177/26335565251323748
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author Maureen Markle-Reid
Kathryn Fisher
Kimberly M. Walker
Jill I. Cameron
David Dayler
Rebecca Fleck
Amiram Gafni
Rebecca Ganann
Ken Hajas
Barbara Koetsier
Robert Mahony
Chris Pollard
Jim Prescott
Tammy Rooke
Carly Whitmore
author_facet Maureen Markle-Reid
Kathryn Fisher
Kimberly M. Walker
Jill I. Cameron
David Dayler
Rebecca Fleck
Amiram Gafni
Rebecca Ganann
Ken Hajas
Barbara Koetsier
Robert Mahony
Chris Pollard
Jim Prescott
Tammy Rooke
Carly Whitmore
author_sort Maureen Markle-Reid
collection DOAJ
description 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.
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spelling doaj-art-448761f63b7d47bb9f74d6f113fb41132025-08-20T03:04:55ZengSAGE PublishingJournal of Multimorbidity and Comorbidity2633-55652025-02-011510.1177/26335565251323748Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive studyMaureen Markle-ReidKathryn FisherKimberly M. WalkerJill I. CameronDavid DaylerRebecca FleckAmiram GafniRebecca GanannKen HajasBarbara KoetsierRobert MahonyChris PollardJim PrescottTammy RookeCarly WhitmoreBackground 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.https://doi.org/10.1177/26335565251323748
spellingShingle Maureen Markle-Reid
Kathryn Fisher
Kimberly M. Walker
Jill I. Cameron
David Dayler
Rebecca Fleck
Amiram Gafni
Rebecca Ganann
Ken Hajas
Barbara Koetsier
Robert Mahony
Chris Pollard
Jim Prescott
Tammy Rooke
Carly Whitmore
Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive study
Journal of Multimorbidity and Comorbidity
title Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive study
title_full Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive study
title_fullStr Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive study
title_full_unstemmed Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive study
title_short Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive study
title_sort implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity a qualitative descriptive study
url https://doi.org/10.1177/26335565251323748
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