Person and Community Centred Approaches to Transitions of Care

The stroke care pathway is complicated, with multiple care settings and partners. Even within highly developed programs of care, with substantial evidence and strong advocacy efforts, stroke survivors still report a multiplicity of health and social challenges after transitioning from the hospital setting into the community. Rehabilitation and recovery supports have been identified as key priorities in stroke research and practice. Once stroke survivors and their families return to life in their homes and communities, hospital readmissions are common, and several other challenges are attributed to care fragmentation, including medication errors, decreased patient/family satisfaction, further morbidity, and even mortality. These issues can be exacerbated in areas where resources and services are lacking, transportation limitations exist, providers are limited or wait times are increased. However, well-facilitated and supported transitions of care and community reintegration could decrease adverse events and re-hospitalization. People-centred and Place-based approaches have emerged as an important foundation for producing a population-level change in outcomes.

“Community-centred” means that an intervention promotes health and well-being or reduces health inequalities in a community setting, using non-clinical methods. It is built upon participatory approaches where service users are actively involved in the design, delivery, and evaluation. Active attention is paid to addressing barriers to engagement and services are built upon the assets of a community in the development and delivery of the program. By collaborating with individuals and groups at most risk of poor health, person- and community-centred approaches to transitional support aim to change the conditions that drive poorer outcomes and increase people’s control over their health and lives.

This Research Topic aims to highlight the newest approaches used and lessons learned by academics and practice leaders conducting research and/or evaluation studies focused on transitions of care for people impacted by stroke. Our goal is to gather the latest advances in the methods ensuring the continuity of care from hospital dismission to home transition and community services, thus improving the quality and efficiency of care for stroke survivors.

We welcome the submission of any type of manuscript supported by the journal (including Original Research, Review, etc.) pertaining to the concepts and approaches to person and community-centred transitions of stroke survivors, including challenges, lessons learned, and future directions across the macro, meso, and micro levels. This collection will include empirically driven manuscripts, commentaries, as well as policy and position papers. reflecting the viewpoints of a broad range of stakeholders. Topics may include, but are not limited to:
- Approaches to strengthening the community through community development, asset-based approaches, or engaging social networks.
- Interventions that have tested volunteer and peer roles in transitions (e.g. community navigation, befriending, or volunteer-delivered services).
- Approaches to collaboration and partnerships to support continuity of care for people impacted by stroke, such as co-production projects, participatory research, or place-based approaches to transitional support.
- Approaches to connect people post-stroke, and their families, to community resources and activities that help them meet their health needs and increase social participation (e.g. social prescribing, green/activity prescriptions, engagement with faith-based services).

Dr Magnus Zingmark holds shares of Rehabguiden M Zingmark AB and ProActive Housing AB. The other Topic Editors declare no competing interests with regard to the Research Topic subject.

Article types and fees

This Research Topic accepts the following article types, unless otherwise specified in the Research Topic description:

• Brief Research Report
• Case Report
• Classification
• Clinical Trial
• Community Case Study
• Data Report
• Editorial
• FAIR² Data
• FAIR² DATA Direct Submission
• ... View all formats

Articles that are accepted for publication by our external editors following rigorous peer review incur a publishing fee charged to Authors, institutions, or funders.

Article types

This Research Topic accepts the following article types, unless otherwise specified in the Research Topic description:

• Brief Research Report
• Case Report
• Classification
• Clinical Trial
• Community Case Study
• Data Report
• Editorial
• FAIR² Data
• FAIR² DATA Direct Submission
• General Commentary
• Hypothesis and Theory
• Methods
• Mini Review
• Opinion
• Original Research
• Perspective
• Policy and Practice Reviews
• Review
• Study Protocol
• Systematic Review
• Technology and Code

Keywords: stroke survivors, person-centered care, transitions, continuity of care, place-based care, social participation, community reintegration

Important note: All contributions to this Research Topic must be within the scope of the section and journal to which they are submitted, as defined in their mission statements. Frontiers reserves the right to guide an out-of-scope manuscript to a more suitable section or journal at any stage of peer review.