Continuity of Care Needs for Home-Based Rehabilitation in Elderly Stroke Patients: A Qualitative Study

Home-based rehabilitation for elderly and frail stroke patients has become an important research area in modern medicine. With the intensifying trend of global population aging, the incidence of stroke among elderly and frail patients is on the rise. Traditional hospital-based rehabilitation models face issues such as high costs and insufficient resources. Home-based rehabilitation, being a more cost-effective alternative, is gradually gaining attention. This study explores the continuity care needs of home-based rehabilitation for elderly and frail stroke patients through qualitative interviews. The findings reveal that the core needs of patients and their families include five themes: demand for professional nursing resources, personalized home-based rehabilitation, prevention and emergency response to complications, support for family caregivers' skill enhancement, and psychological and social support networks. It emphasizes achieving service continuity and risk control through telemedicine coverage, tiered training for family members, multidisciplinary team collaboration, and the application of intelligent monitoring tools.