Stroke-Specific Refinements to Naylor's Transitional Care Model to Address the Storm of Uncertainty and Unmet Survivor and Caregiver Needs

Lorre Laws, Leslie Ritter, Lois J Loescher, Marylyn McEwen

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


BACKGROUND: By 2030, there will be approximately 7.6 million stroke survivors (SSs) in the United States, yet comprehensive transitional care (TC) for stroke is not widely available. Stroke strikes without warning and leaves in its wake a "storm"of uncertainty for SSs and caregivers (CGs) as they encounter a myriad of unmet physical, mental, emotional, and financial needs that are not wholly addressed by passive healthcare delivery systems. Needed is a stroke-specific TC model that bridges this stormto active delivery of SS and CG postacute care. Naylor's Transitional Care Model (NTCM) has not been examined for how it can frame comprehensive stroke care. The purpose of this study was to solicit SS and CG descriptions of TC experiences to inform the NTCM with refined operational definitions and exemplars specific to stroke. METHODS: Focus groups conducted for this qualitative descriptive study were guided by interview questions based on the 8 NTCM operational definitions. Data were analyzed using inductive and deductive qualitative content analysis methods. RESULTS: Post-acute-stroke care does not comprehensively meet the needs of SSs and CGs. Participants described TC deficits across all 8 NTCM components. Two new subcomponents that could be applied for a stroke-specific NTCM emerged: Psychological and transportation challenges. CONCLUSION: Unmet needs identified by SSs and CGs were used to extend NTCM specific to the stroke population and to develop the Recommendations and Exemplars for Stroke Specific Comprehensive Transitional Care Delivery (see Supplementary Digital Content, available at Researchers and practitioners can use the findings to develop and deliver more comprehensive TC to SSs and CGs.

Original languageEnglish (US)
Pages (from-to)23-29
Number of pages7
JournalJournal of Neuroscience Nursing
Issue number1
StatePublished - Feb 1 2022


  • Care continuity
  • Care partner
  • Caregiver
  • Community
  • Recovery
  • Rehabilitation
  • Stroke
  • Survivor
  • Transitional care
  • Transitional care model
  • Transitions of care

ASJC Scopus subject areas

  • Surgery
  • Endocrine and Autonomic Systems
  • Clinical Neurology
  • Medical–Surgical


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