Transitional care interventions and outcome measures in stroke rehabilitation: a scoping review

PURPOSE: Stroke survivors experience physical, emotional, and cognitive-communication impairments, requiring rehabilitation services across multiple care settings. Transitional care interventions (TCIs) are actions to ensure care coordination. This scoping review aimed to describe the intervention components and outcomes of TCIs in stroke rehabilitation. MATERIALS AND METHODS: A scoping review was conducted using 5 databases (PubMed, CINAHL, OVID MEDLINE, PsycINFO, Rehabilitation & Sports Medicine) for the years 2012-2026. After removing duplicates, 4,663 abstracts were screened, and the full text of articles was reviewed. Intervention characteristics, components, and outcomes were extracted from the full-text articles. Descriptive, numeric and narrative summaries were prepared; intervention components and outcomes were categorized. RESULTS: The review included 49 articles, representing 31 TCIs with 23 different intervention components. Interventions predominantly employed individual-level components (education, self-management). System-level components (care coordination) were used less frequently. Clinical outcomes are predominantly focused on physical function. Cognitive-communication outcomes were evaluated less frequently; persons with aphasia and cognitive impairments were often excluded from studies. Implementation outcomes were assessed for 20 TCIs. CONCLUSION: Alignment of individual- and system-level intervention components with intended outcomes is necessary to advance TCI research. Further work is needed to tailor TCIs to the needs of persons with cognitive-communication disabilities.