Background: Brief telephone support after hospital discharge increases patient satisfaction and reduces readmissions in some chronic conditions. We evaluated this type of service in Tasmania for people with stroke.
Methods: Stroke Foundation health professionals call to discuss risk factors and unmet needs around 3 weeks post-discharge following acute care/rehabilitation referral. A survey evaluated referrer knowledge and satisfaction (13 items rated 1 “strongly disagree” to 5 “strongly agree”) with the service. Interviews were conducted with referrers and people with stroke that received the service. Data linkage of recipients to admitted patient care records was used to examine the proportion referred and their characteristics compared to people not referred.
Results: In the survey (n=17), 59% knew about and 60% had referred to the service. The most highly rated satisfaction items among referrers were for the service creating link to primary care (mean 4.5 SD 0.5) and reinforcing risk factor information (mean 4.3 SD 0.5). Across referrer surveys and interviews (n=3), benefits were increasing engagement and reinforcing information. Barriers were consent and timing of call. Recipient interviews (n=9) revealed the service made people feel supported but also frustration at the scope of support. Only 19% (n=342/1783) of stroke discharges were referred during 2019-2020. Compared to non-recipients, recipients were more often male (62% vs 53%), younger (71 vs 73 years) and alive during follow-up (95% vs 90%) but had similar hospital readmissions (mean 4.1 vs 4.2).
Conclusions: A brief telephone follow-up service after stroke was generally well accepted but few people were referred.