The Role of Home Health Care Nurses in the Transitional Care of Stroke Patients from Hospital to Home, King Chulalongkorn Memorial Hospital

Abstract

Stroke is a major global health problem and a leading cause of disability, profoundly affecting patients and their families across physical, psychological, social, and economic dimensions. This impact necessitates increased reliance on care, especially during the critical post-discharge and home-return transition period, where patients and families must adjust to substantial life changes. Consequently, home health care nurses play a crucial role in bridging the transition and supporting continuous care from the hospital to the home. Their support helps patients and families effectively manage self-care, reduce the risk of complications and hospital readmission, and ultimately improve quality of life by utilizing standard, evidence-based care guidelines. Therefore, the objectives of this article are to describe post-discharge stroke and its impact on patients and caregivers, present the concept of the transitional care model (TCM) care system as well as provide guidelines for transitional stroke patients from hospital to home by utilizing the transitional care framework, and explain the roles of home health care nurses in stroke patients. This work is intended to enhance the knowledge of nursing professionals and serve as a guide for further developing a more effective home visit system for stroke patients.