Stroke survivors’ health priorities and targeted interventions in home-based post-discharge rehabilitation

Background This study aimed to describe health problems of the stroke survivors and the corresponding nursing interventions implemented during 12-week home-based post-discharge rehabilitation. Methods This was a descriptive secondary analysis within the context of a randomized controlled trial. Randomly selected raw audio recordings of follow-up calls between nurses and stroke survivors in a home-based post-discharge rehabilitation program were used to assess the intervention characteristics. The research protocol and the Omaha System was adopted to guide the analysis of health needs and nursing practice. Results A total of 459 minutes of audio-recordings from eighty-nine telephone contacts with fifteen participants were analyzed, revealing 22 of the 42 Omaha System health problems across all four domains. The most prevalent issues were “Neuro-musculo-skeletal function” (21.2%), “Circulation” (14.6%), and “Nutrition” (10.6%). The four interventions categories were fully implemented with “Surveillance” being the primary approach (54.6%), followed by “Teaching, Guidance, and Counseling” (35.6%). “Case Management” was crucial for "Health care supervision," and “Treatments and Procedures” were frequently applied to "Neuro-musculo-skeletal function" and "Speech and language" problems. Intervention targets varied significantly across different problem-category matches. Conclusions The Omaha System facilitates the precise identification of critical health issues among stroke survivors during post-discharge home rehabilitation, and enables targeted nursing interventions in addressing the problems. Surveillance and educational strategies are particular vital for rehabilitation support. There is a potential to build a structured care model using information technology that can facilitate the delivery of comprehensive and standardized quality nursing care to ensure the optimal rehabilitation of stroke patients. Trial registration The study was registered as a randomized controlled trial in ClinicalTrials.gov. Registration Date: 2019-3-21, Registration Number: NCT03884621.