Abstract Continuity of care for stroke patients in rural areas is critical, as its absence is a major source of disruption and ineffectiveness in post-discharge support. This study aimed to explore the needs for discharge planning of stakeholders to inform a context sensitive continuity of care for stroke patients in rural Thailand.  A qualitative descriptive study was conducted in Nang Rong District, Buriram, involving 20 purposively selected participants, including healthcare professionals and community stakeholders such as Village Health Volunteers (VHVs) and caregivers. Documentary research and secondary data from hospital records (2022-2024) were also analyzed to triangulate findings. Analysis of hospital records revealed 170 stroke cases and 545 survivors living with residual disabilities in the community database, highlighting a high demand for long term support. Qualitative findings identified four critical prerequisites for improving care: structured discharge planning, clearly defined interdisciplinary roles, efficient data transfer systems, and planned community home visits. Stakeholders emphasized that current care is fragmented, with caregivers often lacking necessary technical skills despite hospital training. To bridge the gap in rural stroke care, a model coordinated by community nurses is vital. By establishing structured pathways and seamless data sharing, healthcare providers can better support recovery and reduce long term disability, transitioning from hospital centric to a participatory community based care model.

Keywords: Continuity of care, Community nursing, Challenges and needs for stroke care, Stroke patients

Citation: Namtaweechaikul, K., Tamdee, D., and Tuanrat, W. 2027. The need for discharge planning in the continuity of care among stroke patients in a rural area of Thailand: A qualitative study. Natural and Life Sciences Communications. 26(1): e2027014.

Graphical Abstract:

INTRODUCTION

The global incidence of stroke continues to rise, despite the implementation of policies and guidelines aimed at improving stroke care, especially in low and middle income countries (LMICs) (Pandian et al., 2020). In Thailand, stroke remains a significant public health concern. Reported mortality rates among stroke patients over the past three years (2020–2022) were 10.35%, 11%, and 10.92%, respectively (Songsrichainun and Tiamkao, 2024). With the advancement of healthcare services, stroke survival rates have improved. However, many stroke survivors continue to experience chronic conditions or disabilities, requiring long term care. This extended care period places a significant burden on caregivers, particularly after patients are discharged from the hospital (Chen et al., 2022). A review of existing stroke care systems reveals gaps in the discharge and referral processes, including insufficient preparation for patients to return home and unclear pathways for community reintegration. Caregiver preparation also remains inadequate due to fragmented healthcare service systems and poor data connectivity. Current analyses indicate that the healthcare system in Thailand is still fragmented, resulting in complex and uncoordinated care, especially for stroke patients, who require multidisciplinary rehabilitation services from both hospitals and home care providers. Understanding patients’ needs throughout the continuity of care is critical to shifting toward more patient centered and integrated stroke care (Bally et al., 2023). While increased survival rates suggest medical improvements, they also correlate with higher rates of disability. Therefore, comprehensive stroke care from acute care to rehabilitation services in both community and home settings is essential for ensuring patient safety and reducing long term disability (Wasti et al., 2021). Although Thailand has developed a stroke care service plan, actual implementation, particularly in rural areas with limited resources and accessibility, remains challenging.

Continuity of care for post discharge patients was hindered by a lack of multidisciplinary coordination. As a result, both patients and caregivers often lack adequate information and skills for effective home care, leading to diminished confidence in providing ongoing care (Lin et al., 2023). Moreover, incomplete discharge information, poor communication between hospitals and communities, unclear home visit criteria (Tewela et al., 2023), lack of post discharge home visits by health professionals, and fragmented rehabilitation services further hinder effective continuity of care. Home preparedness and the presence of a supportive social network are crucial for successful recovery after hospital discharge (Iwasa et al., 2024; Falk Johansson et al., 2025). From the previous information about the problems of the continuity of care system for stroke patients, including the severity of chronic diseases, health care services systems, and the factors related to new stroke patients, it is necessary to study and explore in more detail about the health problem, care problems situation and needs of stakeholders. To develop a clear and standardized continuity of care system to promote efficient patient care processes by the end.

While Thailand has established a national stroke care service plan, there remains a significant gap between policy and clinical practice in resource limited rural settings. (Pandian et al., 2020; Wasti et al., 2021) Existing research often focuses on urban clinical outcomes, leaving a gap in understanding the lived sociocultural challenges and systemic barriers such as fragmented data connectivity and caregiver role rotation specific to rural communities like Buriram. This study addresses this gap by providing an in depth exploration of stakeholders’ needs to inform a context sensitive continuity of care model.

This study aimed to explore the needs for discharge planning of stakeholders to inform a context sensitive continuity of care for stroke patients in rural Thailand. who are discharged from the hospital and referred to home, which is a critical period in the rehabilitation of stroke patients. Understanding these factors is essential for identifying unmet needs and enhancing the continuity of care to inform the development of effective models or guidelines for long term stroke care. Understanding the situation, problems, issues, and needs of stakeholders will help to reduce unmet needs during the continuum of care (Chen et al., 2022). To use the obtained information to develop guidelines or models for caring for stroke patients.

MATERIALS AND METHODS

Design

A qualitative descriptive design was employed to gain a comprehensive, straightforward understanding of the specific needs and barriers regarding continuity of care for stroke patients in a rural Thai community. This study aimed to explore the needs for discharge planning among stakeholders to inform a context sensitive continuity of care, while identifying challenges, obstacles, and potential strategies for developing a collaborative model for stroke patients in the community. The study area was selected using purposive sampling. Initially, a primary care setting the Primary Care Unit (Nang Rong), under the Nang Rong Subdistrict Administrative Organization in Nang Rong Subdistrict, Nang Rong District, Buriram Province was selected. Subsequently, Nang Rong Hospital was purposively selected as the secondary care facility, as it is the only hospital in the district with a dedicated stroke unit.

Participants

Participants were selected through purposive sampling, focusing on 20 individuals with diverse roles relevant to stroke care. To be included, healthcare staff had to have at least 6 months of experience in stroke care, while caregivers and VHVs had to reside in the target area. The exclusion criteria included individuals with severe communication barriers, those who planned to relocate or take extended leave during the study, or those who withdrew before completing the interview process. Data collection through semi-structured interviews continued until data saturation was reached, where no new themes emerged. Additionally, secondary health records and policy documents were analyzed separately to provide contextual information and support the interview findings. The participants were categorized into two main groups: 1) Healthcare team, including registered nurses from the stroke unit, internists, a pharmacist, a physical therapist, a nurse responsible for continuity of care, and a nurse from the Primary Care Unit (Nang Rong) responsible for home visits; and 2) Community stakeholders, including Village Health Volunteers (VHVs), informal caregivers, community leaders, public health and environmental officers from the Nang Rong Subdistrict Administrative Organization, and primary caregivers of stroke patients residing in the community. All participants provided informed consent and voluntarily agreed to participate in the study.

The study sample comprised two distinct stakeholder groups totaling 20 participants, rational driven by their specific roles in stroke care:

Healthcare Team (n = 7): This sample included all key multidisciplinary personnel directly involved in the stroke continuum of care within the district network (1 physician, 1 pharmacist, 1 physical therapist, and 4 registered nurses representing the Stroke Unit, home health care unit, and Primary Care Unit). This represented total population sampling of the core multidisciplinary team in this local context.  

Community Stakeholders (n = 13): To capture a holistic community perspective, purposive sampling was used to select participants across diverse roles, including Village Health Volunteers (n=5), primary caregivers (n=3), caregiver volunteers (n=2), community leaders (n=2), and a public health officer from the Subdistrict Administrative Organization (n=1). Data collection within this group was guided by data saturation, which was achieved at 13 participants when no new operational barriers or unmet needs emerged.

Given the distinct roles and perspectives between healthcare professionals and community stakeholders, the qualitative findings were first analyzed and presented by stakeholder category to clearly delineate their specific situational problems, barriers, and unmet needs, before synthesizing them into overarching core requirements.

Research instruments

Semi-structured interviews

Semi-structured interviews were conducted with community stakeholders to collect data regarding the problems, needs, and barriers related to the continuity of care for stroke patients. For the healthcare team, the interviews focused on three key aspects: (1) Discharge planning (2) Information referral and transfer and (3) Home health care services.

Documentary Research Data were collected through documentary research by reviewing and analyzing existing clinical practice guidelines for stroke patient care.

Secondary Data Collection Form A researcher developed secondary data collection form was used to gather information from relevant organizations regarding the evaluation of stroke patients in the community. The form consisted of three main sections: (1) The knowledge and skills of patients and family members in providing continuity of care before hospital discharge (2) Patients requiring intermediate care (IMC) (3) Data from Nang Rong Hospital related to stroke care in the community.

Functional Assessment Tools (1) The Barthel Index of Activities of Daily Living (ADL) (2) The Modified Rankin Scale (mRS.) These tools were used by the Buriram Stroke Network to assess patients' ability to perform daily activities and the degree of disability.

Guideline based Data Collection Additional data were gathered from recommendations outlined in clinical practice guidelines for stroke care, as well as from the implementation process of those guidelines in Nang Rong Hospital.

The research tools were validated by a panel of six experts, including one specialist in rehabilitation medicine, one specialist in family medicine, two community nurse practitioners, one stroke nursing specialist, and one academic expert in community health nursing. The experts assessed the tools for content appropriateness, clarity of the questions, and comprehensiveness. The overall Content Validity Index (CVI) for the scale was 1.00, indicating excellent content validity. To ensure trustworthiness, the study employed data triangulation by comparing interview transcripts with clinical guidelines and hospital statistics. Furthermore, member checking was performed by sharing transcribed data with participants to verify the accuracy of their shared experiences.

Data analysis

Qualitative data were analyzed using qualitative content analysis. To ensure rigorous data triangulation across multiple data sources, specific analytical procedures were applied to each data type

• Transcripts (Interviews and Focus Groups): Audio recordings were transcribed verbatim and analyzed using content analysis to identify stakeholders' needs, gaps, and operational barriers in stroke care.

• Field Notes: Observational field notes capturing participants' non-verbal behaviors, emotional expressions, and environmental contextual factors were analyzed concurrently with transcriptions to enrich thematic interpretation.

• Documentary and Secondary Data: Clinical practice guidelines (CPGs) for stroke care, hospital annual reports, and secondary database records (e.g., 170 hospital stroke cases and 545 community stroke survivors with residual disabilities, as well as Barthel Index/mRS scores) were analyzed via document review. These data established clinical standards and baseline epidemiological demands, which were cross examined against qualitative interview themes to confirm system barriers and unmet needs.

Ethical consideration

Ethical approval for this study was granted by the Research Ethics Committee, Faculty of Nursing, Chiang Mai University. Further project certification was obtained from the Institutional Review Board (IRB), under approval number 2567 – EXP011, effective January 30, 2024. Prior to participation, researchers thoroughly explained the study's objectives and procedures to all prospective participants. Participants were explicitly informed of their right to consent or decline participation, and that they could withdraw from the study at any point without any adverse impact on their ongoing medical treatment. All data collected will be maintained with strict confidentiality, utilizing appropriate personal data protection measures. This data will be exclusively used for academic analysis, ensuring that personal identifying information remains undisclosed. All collected data will be destroyed one year following its publication.

Data collection

Data collection commenced in February 2024 and concluded in January 2025, following approval from the research ethics committee. The researcher utilized semi-structured interviews and focus group discussions conducted in a relaxed, quiet environment free from external disturbances. Interview times were scheduled at the participants' convenience. Permission was obtained to record all interviews, with each session lasting approximately 30 minutes. Data was collected over one to two sessions per participant.

Immediately after each interview, the researcher transcribed the audio recordings verbatim. The transcriptions were then reviewed for clarity by listening to the recordings again. If any points were unclear, the researcher arranged follow up interviews with the participants for clarification. The transcribed data was also shared with participants for their review, ensuring the information accurately reflected their experiences. Data collection continued until data saturation was achieved.

To comprehensively identify the unmet needs for discharge planning, the semi-structured interview guide was designed using a diagnostic and evaluative approach. The interviews commenced by exploring participants lived experiences regarding the current situation, strengths, weaknesses, and operational barriers in past stroke care transitions. Grounding the inquiry in these baseline gaps and system challenges enabled stakeholders to reflect deeply and articulate context specific needs and practical strategies essential for establishing an integrated continuity of care model.

•   What were the strengths, weaknesses, and unmet needs in post discharge planning models for stroke patients?

•   What specific barriers exist in the patient referral system, and what essential resources or protocols are needed to streamline this process?

•   What are your specific needs and recommendations regarding post-discharge home health care delivery in the community?

Similarly, to deeply understand the discharge planning context, the semi-structured interviews for healthcare stakeholders began by exploring their perspectives on current operational strengths, weaknesses, situational gaps, and unmet needs during hospital-to-home transitions, as well as specific barriers in referral processes, before leading into key prerequisites for system improvement. The key topics included:

•   From your role, what challenges exist in continuity of care, and what specific support or resources do you need to manage these issues effectively?

•   What are the gaps in current home health services, and what essential needs must be addressed to improve home care quality?

•   What is your opinion on the outcomes of past discharge planning continuity of care for stroke patients in the community?

•   What key factors and support mechanisms are needed to enhance home visits and caregiver preparedness?

RESULTS

The findings are integrated from three primary data sources: semi-structured interviews, focus group discussions, and a review of hospital records and clinical practice guidelines. Analysis of secondary health records revealed a high demand for long term stroke care in the study area, with 170 stroke cases (159 ischemic and 11 hemorrhagic) recorded at Nang Rong Hospital between 2022 and 2024, and 545 stroke survivors with residual disabilities currently registered in the community database.
A total of 20 participants were included in this study, divided into two key stakeholder groups:

Healthcare team: Stakeholders 7 healthcare providers participated in this study, predominantly female (71.4%) with an average age of 37.71 years (SD = 5.99). Registered nurses represented more than half of the team (57.1%), alongside 1 physician, 1 pharmacist, and 1 physical therapist (14.3% each). Regarding work experience in stroke care, 4 participants (57.1%) had worked for 5 years or less, while three participants (42.9%) had 5 years or more of experience.

Community stakeholders: The community stakeholder group comprised 13 participants, mostly female (92.3%), with a mean age of 47.69 years (SD = 10.65). Agriculture was the primary occupation for nearly half of the sample (46.1%). By role in community stroke care, Village Health Volunteers (VHVs) made up the largest group (38.4%), followed by primary caregivers (23.1%), caregiver volunteers (15.4%), community leaders (15.4%), and one local public health officer (7.7%). Over half of the participants (53.8%) had 10 years or less of experience in community care, while 6 participants (46.2%) had served for more than 10 years.

Currently, the treatment process for stroke patients follows the Stroke Fast Track system, which includes standardized clinical protocols to ensure effective patient care outcomes. One of the key performance indicators is the "door to refer time", which should not exceed 30 minutes. After initial screening, patients suspected of having a stroke and who are eligible for thrombolytic therapy or who require more complex interventions beyond the hospital’s capacity are promptly referred to specialized centers. Other patients continue their treatment in the stroke unit, following clinical practice guidelines. Once a patient’s condition stabilizes, early rehabilitation begins. When the patient improves and is medically fit for discharge, the physician will discharge them home. At this point, patient information is transferred through the https://coc.thaicarecloud.org (Thai COC program) to the Subdistrict Health Promoting Hospital, where continued care and rehabilitation services are provided. Home based rehabilitation programs are delivered by a multidisciplinary team, including Subdistrict Health Promoting Hospital staff and village health volunteers (VHVs), to support continuity of care at home. However, challenges remain. Caregivers often lack sufficient knowledge and practical skills to manage stroke care effectively across settings from hospital to home. This is due to the rotational nature of caregiving at the hospital, which can result in incomplete knowledge transfer and inconsistent skill training, thereby increasing the risk of complications once the patient returns home. Furthermore, care coordination remains fragmented, as information transfer between healthcare units may be poorly structured and lacks designated personnel responsible for continuity of care. In addition, there are no clearly defined protocols for follow up and home based rehabilitation, which is often inconsistent or inadequately supported by key community stakeholders, such as local administrative organizations, community leaders, and other related sectors.

The qualitative findings revealed that stakeholders' unmet needs for discharge planning and care continuity were fundamentally informed by the operational barriers, structural weaknesses, and situational gaps they experienced in practice. Given the distinct roles between healthcare professionals and community members, the results are presented in two integrated stages. First, the specific situational problems, barriers, and resulting needs are detailed by stakeholder category (Healthcare Team vs. Community Stakeholders). Second, these group-specific needs were synthesized into Four Critical Prerequisites necessary for an integrated, context-sensitive continuity of care model.

1. Healthcare team perspectives: Situational gaps and core needs

Healthcare professionals highlighted that short hospital stays limit discharge preparation time, while care planning remains discipline-siloes with separate documentation systems. Information given to families is often overly complex, and orientation sessions are frequently attended by secondary rather than primary caregivers. Consequently, the healthcare team expressed an urgent need for a unified, interdisciplinary discharge protocol, simplified caregiver educational materials, automated referral notification systems, and cross-specialty skill-sharing.  

2. Community stakeholders perspectives: Operational challenges and core needs

Community stakeholders (caregivers, VHVs, and local leaders) emphasized that primary caregivers face practical skill deficits upon returning home, exacerbated by irregular follow-up visits and financial constraints. These challenges generated a paramount need for structured, hands on skill training prior to discharge, scheduled multidisciplinary home visits, and a designated community nurse care coordinator.  

Synthesis of unmet needs: The 4 Critical Prerequisites for Continuity of Care Synthesizing the situational gaps and unaddressed needs across both stakeholder groups yielded four core prerequisites essential for establishing a context-sensitive continuity of care model: Structured Discharge Planning: Addressing caregiver skill deficits and information overload through structured, practical training.   Defined Interdisciplinary Roles: Overcoming unclear role boundaries by establishing standardized clinical pathways across hospital and primary care settings.   Efficient Data-Transfer Systems: Resolving fragmented communication through automated data-transfer platforms and designated care coordinators.   Planned Community Home Visits: Mitigating irregular follow-up through scheduled, multidisciplinary home visits and continuous community support.  

1. Structured discharge planning

The study revealed that although most caregivers received general guidance from hospital nurses regarding home care, many struggled to implement the recommended care practices after returning home. This gap was driven by a lack of practical skills, knowledge deficits, and information overload from multiple disciplines. Additionally, frequent rotations among secondary caregivers exacerbated the discontinuity of care. Representative stakeholder statements include:

“Caregivers receive an overload of information from various healthcare professionals, making it hard to follow.” (Professional Nurse in the Stroke Unit)

“I believe the issue lies in the caregivers’ lack of knowledge and skills.” (Community Leader)

“It may be due to a lack of medical equipment at home.” (Village Health Volunteer)

2. Defined interdisciplinary roles

The study identified significant gaps in multidisciplinary care execution, driven by unclear role delineation and the absence of standardized clinical pathways in primary care settings. Healthcare professionals noted that short hospital stays combined with weekend staffing constraints often forced individual nurses to fulfill roles beyond their primary expertise. Furthermore, fragmented record-keeping and unsuitable educational materials compounded care discontinuity. Representative stakeholder statements include:

“There is no applicable standard protocol for stroke care.” (Professional Nurse in the Stroke Unit)

“Sometimes nurses on weekend shifts must advise patients in place of the multidisciplinary team.” (Professional Nurse in the Stroke Unit)

“Alternative caregivers lack the skills and knowledge to care for older adults when the primary caregiver is unavailable.” (Professional Nurse in the Stroke Unit)

“There is no communication or collaboration among the multidisciplinary team.” (Physical Therapist)

“Patient and caregiver records are kept separately by each discipline, resulting in discontinuity.” (Professional Nurse in Home Health Care unit)

“Educational materials are not suitable some caregivers are young, some elderly, and they can’t understand them.” (Professional Nurse in the Primary Care Unit)

Although caregivers reported receiving basic discharge preparation, stakeholders emphasized a pressing need to enhance practical caregiving skills. Furthermore, healthcare personnel stressed that discharge planning remains fragmented across disciplines, requiring structured interdisciplinary collaboration to ensure seamless care transition.

3. Efficient data transfer systems

The study also highlighted deficiencies in the transfer of information from hospitals to community based healthcare providers. This includes the absence of a designated care coordinator and a lack of notification systems, which results in delayed communication. Relevant stakeholder opinions include:

“The problem partly stems from the absence of a care continuity coordinator, leaving families with no direct channel to contact the primary care unit after returning home.” (Village Health Volunteer).

Consequently, this lack of localized coordination meant that even when community based healthcare providers were physically close, the systemic disconnectedness delayed necessary nursing interventions during the most vulnerable period of recovery.

“Incomplete information is transferred there is no standard referral documentation.” (Professional Nurse in Home Health Care Unit)

Overall, while Thailand's tiered healthcare referral system is well established, the mechanisms for information transfer and explicit role delegation remain unclear. The absence of a standardized referral document and inconsistent use of digital platforms lead to delayed and fragmented care continuity.

4. Planned community home visits

Stroke patients discharged from the hospital require ongoing care, including rehabilitation, secondary prevention of disability, and support for independent living to improve their quality of life. However, stakeholders reported that caregivers, both professional and informal, often lack the skills needed to manage sudden health changes or to provide comprehensive rehabilitation. There is a strong need for multidisciplinary support to prepare both patients and families for home based care, including systematic home visits and ongoing follow-up. Supporting stakeholder statements include:

“Nurses are not proficient in physical therapy techniques.” (Professional Nurse in the Primary Care Unit)

Challenges in home care have often impacted on the quality of care received by stroke patients, as reflected in the following remarks:

“There should be serious follow up home visits by village health volunteers and nurses, as the current irregular visits leave caregivers feeling overwhelmed and helpless in managing the patient's deteriorating condition at home.” (Caregiver Volunteer)

“Hospitals should ensure the home is prepared before the patient is discharged.” (Professional Nurse in the Primary Care Unit).

DISCUSSION

The discussion focuses on the four critical prerequisites identified in the results, addressing the real world context, systemic challenges of rural healthcare, and specific stakeholder needs for an integrated continuity of care model. The findings from this study revealed a variety of perspectives, experiences, and needs among stakeholders involved in stroke care, highlighting critical issues that affect the continuity and quality of care for stroke patients transitioning from hospital to home. These findings underscore several key themes.

The importance of structured discharge planning and readiness preparation

Stakeholders emphasized the need for a systematic and comprehensive discharge planning process. Providing stroke patients and their caregivers with clear, relevant, and tailored information, alongside proper training in care skills, was seen as essential in improving rehabilitation outcomes. This is consistent with the findings of Saucedo-Pahua et al. (2024), who noted that nurses play a pivotal role in equipping caregivers with skills related to care management, communication, self care, rehabilitation, and nutrition. Technology was also identified as a potential enabler for high quality, home based care. The high number of stroke survivors with residual disabilities in the study area 545 cases underscore the urgent need for long term rehabilitation support. This quantitative evidence aligns with the qualitative findings where stakeholders expressed a strong demand for systematic home based care to prevent secondary complications.

Interprofessional collaboration in stroke care

The study revealed the need for clearly defined roles and responsibilities within the healthcare team, and the importance of close communication and collaboration among interdisciplinary professionals. Effective teamwork was viewed as crucial in formulating and delivering care plans that are both coherent and responsive to patient and caregiver needs. These observations align with the study by Ikeda and Sasada (2024), which found that interprofessional collaboration significantly improved the functional outcomes and daily living abilities of stroke patients.

Inefficiencies in information transfer

The transition from hospital to community care was frequently hindered by poor communication and incomplete transfer of patient data. Such gaps were reported to delay treatment and increase the risk of errors. These findings are supported by Desmedt et al. (2021), who found that delays or inaccuracies in data handover can compromise patient safety and continuity.

Gaps in community and home health services

Participants reported inconsistencies and a lack of follow through in home visits and rehabilitation support. Ljungholm et al. (2022) similarly observed that post-discharge rehabilitation was often insufficient, particularly in community based settings, impacting the recovery of stroke patients. In this study, more than half of the stakeholders had fewer than 10 years of experience in community stroke care, possibly reflecting a need for capacity building and standardization in home health service delivery.

Responding to the needs of patients and caregivers

The voices of community stakeholders, including village health volunteers and caregivers, highlighted the importance of empowering laypersons involved in stroke care. Previous research (Chen et al., 2022; Chingchit et al., 2026) supports the view that adequately trained caregivers, supported by health professionals, can reduce complications and improve care outcomes.

The need for continuity of care models and standardized guidelines

A recurring theme in this study was the absence of clear, standardized guidelines for home based stroke care. The findings echo those of Akgül et al. (2023), who advocated for the development of national or community level standards to support stroke rehabilitation outside hospital settings. Additionally, participants emphasized the need for care models that span across the four critical prerequisites: structured discharge planning, defined interdisciplinary roles, efficient data transfer, and planned community home visits. This holistic framework aligns with the recommendations of Bahadoram et al. (2024), who highlighted the role of continuity in optimizing stroke patient outcomes after discharge.

The role of nurses as coordinators of care transitions

The study also pointed to the vital role nurses can play as care coordinators, bridging the gap between hospital and home settings. Effective coordination not only minimizes duplication of services but also ensures smoother transitions and higher quality of care, consistent with Möckli et al. (2023) and Ljungholm et al. (2022), who emphasized the importance of communication and coordination in supporting patients’ return to the community.

Based on these qualitative findings, it is evident that stakeholders involved in organizing stroke patient care services expressed diverse situations, problems, and needs.Comprehensive and systematic discharge planning encompassing the provision of relevant information and thorough patient preparation is essential to optimizing patient outcomes. The delivery of clear appropriate information combined with effective knowledge transfer and training in care skills has been shown to enhance rehabilitation outcomes. As Saucedo-Pahua et al. (2024) demonstrated, systematic discharge planning is a critical component of care with nurses identified as key facilitators in building patient knowledge and competencies across multiple domains including personal care communication, self-management, rehabilitation, and nutrition. This also includes leveraging technology to ensure quality home care. Defining the roles and responsibilities of each profession, along with close communication and collaboration within the multidisciplinary team for care planning and information dissemination to patients and caregivers, is vital for efficient stroke patient care. Similarly, a study by Ikeda and Sasada (2024) revealed that interprofessional collaboration in patient care improves activities of daily living and enhances the quality of life for stroke patients. Ineffective information transfer, unclear communication, or incomplete information handovers between healthcare facilities can lead to significant issues. Efficient and effective information exchange between hospitals and communities is essential for quality continuity of care, helping reduce delays or errors in treatment. Furthermore, a study by Desmedt et al. (2021) indicated that incomplete, delayed, or misinterpreted information transfer increases the risk of diagnostic errors, delays in care, and ultimately patient harm. It may also hinder the planning of continuity of care in the community, affecting access to services and potentially leading to infrequent or inconsistent home visits.   

According to Lindblom et al. (2024), addressing the 'poorly functioning' transition phase necessitates a holistic, multicomponent approach. By integrating person centred dialogue and technological solutions like e meetings, healthcare systems can mitigate the risks of information loss. This structured transition directly supports the continuity of care advocated by Bahadoram et al. (2024) and addresses the specific community dwelling needs identified by Chingchit et al. (2026). Previous studies from various countries suggest that responding to the needs of patients, caregivers, and other stakeholders contributes to the development of a high quality continuity of care system. For example, good pre-discharge planning combined with the involvement of caregivers who have received proper training in care skills and knowledge can effectively reduce complications in stroke patients. The continuous transfer of relevant information after hospital discharge ensures comprehensive care (Chen et al., 2022; Ljungholm et al., 2022). In conclusion, improved communication is essential for linking continuity of care, facilitating recovery and reintegration into the community, and supporting smooth transitions between care settings. Home healthcare services, therefore, require clear care guidelines. The development of standardized guidelines or criteria for stroke patient home care is crucial, particularly for initial care in the community (Akgül et al.,2023)

Given that the transition from hospital to home care is a critical and vulnerable period for stroke patients and their families, care system development should prioritize patient and caregiver preparedness, coordination between healthcare facilities and the community, and ongoing support. To achieve greater clarity in system development, in addition to considering individual patient differences in needs, capabilities, and access to healthcare services (to allow for appropriate resource allocation and service design), continuity of care must be based on interprofessional collaboration, clear role delineation, and continuity of data. Various factors have influenced continuity of care in the past. Therefore, a guideline or standardized procedure for community based stroke patient care should be developed, covering four core prerequisites: structured discharge planning, defined interdisciplinary roles, efficient data transfer systems and planned community home visits. These should provide information and support to patients both during hospitalization and after discharge (Bahadoram et al., 2024). Nurses should serve as key coordinators to facilitate smooth transitions between healthcare settings and reduce service duplication. The researcher will thus compile and analyze the collected data to support the improvement and development of a participatory continuity of care model for stroke patients in the community.

Limitations of the study

This study was conducted specifically in a rural district of Buriram Province, focusing on the connection between a secondary care facility and its primary care network. Therefore, the findings reflect the unique challenges and stakeholder needs within a rural secondary healthcare infrastructure. While these insights are highly useful for managing and improving transitional care systems in similar secondary care settings, they may not be fully generalizable to urban environments, tertiary medical centers, or regions with different primary care structures.

CONCLUSION

This study highlights the critical importance of ensuring continuity of care for stroke patients during the transition from hospital to home, a particularly vulnerable time with significant impacts on patient recovery outcomes. Key factors influencing the effectiveness of transitional care include comprehensive discharge planning, effective communication and information transfer, appropriate home health services, interdisciplinary collaboration, the crucial role of community nurses as care coordinators, and the active participation of caregivers and community stakeholders, all essential to creating a seamless and integrated care system. However, this study also identified ongoing challenges, such as a lack of standardized care pathways, fragmented services, and inadequate community level support mechanisms.

Based on the unique sociocultural context of rural Buriram identified in this study characterized by a high prevalence of post stroke disability and fragmented community support developing a structured model for transitional care is essential. Therefore, such a model should incorporate four key prerequisites: systematic discharge planning, clear and effective information transfer, defined interdisciplinary roles, and planned community home visits by community nurses. This model should be contextually tailored to meet the individual needs of stroke patients and reflect the local community landscape. Ultimately, community nurses play a crucial role in coordinating and strengthening the integration between hospital and community services to improve quality of life, support recovery, and reduce long-term complications in stroke survivors.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge all participants for their valuable time and contribution to this study.

AUTHOR CONTRIBUTIONS

Kittiphon Namtaweechaikul: Conceptualization (Lead), Methodology (Lead), Formal Analysis (Lead), Validation (Lead), Resource (Equal), Data Curation (Equal), Writing–Original Draft (Equal), Writing – Review & Editing (Lead), Validation (Equal), Resource (Equal),  Investigation (Equal), Supervision (Equal), Project administration (Lead); Decha Tamdee: Conceptualization (Supporting), Methodology (Supporting), Data Curation (Equal), Resource (Equal), Formal Analysis (Supporting), Validation (Equal), Resource (Equal), Writing – Original Draft (Equal), Data Curation (Equal), Writing–Review & Editing (Supporting), Investigation (Equal), Project administration (Supporting); Wilawan Tuanrat: Methodology (Supporting), Formal Analysis (Supporting), Validation (Equal), Resource (Equal), Data Curation (Equal), Writing – Review & Editing (Equal), Investigation (Supporting), Supervision (Equal).

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

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