Objectives: To examine the feasibility and acceptability of a 6-month transitional care intervention linking outpatient rehabilitation and community-based care, and to explore its preliminary effects on patient and provider outcomes and health service use and costs for older adults with stroke and multiple chronic conditions.

Methods: A mixed-methods study (QUAL + quant) was used to examine the feasibility of the intervention and to explore its effects on quality of life, self-efficacy, depression, anxiety and health service use and costs. The tailored 6-month stroke rehabilitation intervention was delivered by an interprofessional (IP) team and supported by a web-based app, ‘My Stroke Care (MYST)’. 

Results: Of the 30 participants, 60% had ≥ 6 chronic conditions, 47% had depressive symptoms, 13% had moderate to severe anxiety, and 54% were hospitalized for ≥16 days in the past 6 months. Preliminary findings suggest the intervention is feasible and acceptable to the IP team and older adult participants. Providers perceived the following benefits associated with the intervention: increased connectedness with community resources, increased communication and coordination between inpatient and outpatient teams, increased use of stroke best practices, increased understanding of patients’ needs, and increased focus on patient-oriented goals and strengths. Significant improvement was seen in patients’ self-efficacy (p=0.04) and a reduction in hospitalizations (p < 0.0001) over the study period. 

Conclusions: The findings support the feasibility and preliminary effectiveness of the intervention in improving patient outcomes, building capacity among an outpatient rehabilitation team, and using MYST as a platform for information sharing and goal setting.

IMPLEMENTATION AND EVALUATION OF TRANSITIONAL CARE INTERVENTION LINKING HOSPITAL-BASED OUTPATIENT REHABILITATION AND COMMUNITY-BASED CARE FOR OLDER ADULTS WITH STROKE AND MULTIPLE CHRONIC CONDITIONS