@entity64 rehabilitation involves care issues concerning the physical, psychosocial and spiritual aspects. Hospital-based rehabilitation has its limitations because many of the care issues only emerge when @entity1 return home. Transitional care models supporting @entity1 after discharge from the hospital have proved to be effective among chronically ill @entity1 , but limited studies were conducted among @entity64 survivors. This study was a randomised controlled trial conducted to test the effectiveness of a @entity1606 ( @entity1606 ) which was a nurse-led 4-week programme designed based on the assessment-intervention-evaluation Omaha System framework. Between August 2010 and October 2011, 108 @entity64 @entity1 who were discharged home, able to communicate, and had slight to moderate @entity51 and disability were randomised into control (n  =  54) and intervention groups (n  =  54). Data on the @entity1 -related and clinical outcomes were collected at baseline, 4  weeks when the @entity1606 was completed and 8  weeks after discharge from hospital. Repeated measures analysis of variance with intention-to-treat strategy was used to examine the outcomes. There were significant between-group differences in quality of life, the primary outcome measure of this study, in both physical (F(1, 104)  =  10.15, P  =  0.002) and mental (F(1, 104)  =  8.41, P  =  0.005) domains, but only the physical domain achieved a significant time  *  intervention interaction effect (F(1, 103)  =  7.73, P  =  0.006). The intervention group had better spiritual-religion-personal measures, higher satisfaction, higher Modified Barthel Index scores and lower @entity308 scores when compared with the control group. They also had lower hospital readmission and use of emergency room rates, but only the use of emergency room had significant difference when compared to control. This study is original in testing a transitional model among @entity64 @entity1 discharged from hospital. The @entity1606 shares common features that have been proved to be effective when applied to chronically ill @entity1 , and the duration of 4  weeks seems to be adequate to bring about immediate effects.

Effects of a 4-week @entity1606 for discharged XXXX survivors in Hong Kong: a randomised controlled trial.

@entity1 :: ('9606', 'Species') :: ['patients', 'patient'] @entity64 :: ('MESH:D020521', 'Disease') :: ['stroke', 'Stroke'] @entity308 :: ('MESH:D003866', 'Disease') :: ['depression'] @entity51 :: ('MESH:D009461', 'Disease') :: ['neurological deficits'] @entity1606 :: ('MESH:D002295', 'Disease') :: ['transitional care programme', 'TCP']
@entity64 :: (MESH:D020521,Disease) :: ['stroke']
