Introduction
The management of acute ischemic stroke has significantly evolved in recent years, with advancements in reperfusion therapy during the hyperacute phase, in-hospital care, and comorbidity treatments.1 While reperfusion therapy has notably enhanced short-term functional outcomes, many stroke survivors still require structured rehabilitation programs,2 ongoing disability care, and preventive measures against stroke recurrence post-acute phase.3,4
Historically, post-discharge management and rehabilitation heavily relied on prompt outpatient follow-ups. However, challenges such as limited health literacy, ineffective self-care practices, and low medical adherence could undermine treatment effectiveness.5,6 To address these issues, emerging discharge plan services now operate as cohesive multidisciplinary teams, offering patient-centered support through customized strategies for post-discharge care. These strategies include outpatient rehabilitation, intensive programs like Post-Acute Care-Cerebrovascular Disease (PAC-CVD) rehabilitation,7–9 and home care services provided by Long-Term Care 2.0 (LTC 2.0), and integrated community-based long-term care system designed for individuals with functional limitations in Taiwan.10–12
Drawing data from a single hospital-based stroke registry, we examined the utilization of continuous care among acute stroke survivors and assessed 3-month outcomes. The study aimed to identify potential areas of improvement and offer valuable insights to enhance the performance of relevant care providers.
Materials and Methods
Study Design and Subjects
The study subjects were assembled from the hospital-based prospective stroke registry at Chi Mei Medical Center, a teaching hospital, with around 1300 beds in Southern Taiwan. This registry prospectively enrolled all patients admitted within 10 days of stroke onset, adhering to predefined criteria outlined in the nationwide Taiwan Stroke Registry.13 Data collection included structured information such as demographics, medical history, comorbidities, stroke severity, treatments, hospital course, complications and discharge disposition. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and functional status pre-admission and at discharge was categorized using the modified Rankin Scale (mRS). The registry was approved by the Ethics Committee of Chi Mei Medical Center.
For this retrospective observational cohort study, patient diagnosed with transient ischemic attack (TIA) or acute ischemic stroke between July 2021 and June 2022 were included. Exclusions were in-hospital strokes, deceased subjects at discharge, and those discharged against medical advice.
Baseline Assessment
Subjects were categorized based on their discharge mRS scores as follows: I (0–2), II (3), and III (4–5), indicating no/mild, moderate, and severe disability in functional status, respectively. Data collected from the stroke registry included demographic details, NIHSS scores at admission and discharge, length of hospital stay, TOAST subtype classification, acute reperfusion therapy, stroke risk factors (diabetes mellitus, hypertension, dyslipidemia, atrial fibrillation, ischemic heart disease, heart failure, prior stroke history, dialysis, smoking, and cancer), indwelling of nasogastric tube or urinary catheter at discharge, and discharge destination. Information regarding discharge planning preparations, such as PAC-CVD program involvement, home-based medical care, nursing institution placements, Long-Term Care 2.0 services, and hospital transfers, were retrieved from medical records.
Outcome of Interest
The study examined clinical adherence, readmissions within three months of stroke onset, and 3-month mRS. Data for these outcomes were collected from medical records and through telephone interview conducted by stroke case managers.
Clinical adherence in our study was defined as receiving scheduled appointments at any medical facility, either by clinic visits or home-based medical care. Patients lost to follow-up were those who could not be reached even through telephone contacts.
Statistical Analysis
Continuous variables were expressed as median (interquartile range) given their departure from normal distribution, while categorical variables were presented as proportions. Intergroup comparisons were conducted using the Kruskal–Wallis test for continuous variables and Pearson’s chi-square or Fisher’s exact test for categorical variables. All p-values were two-sided, with statistical significance set at α < 0.05. Analyses were performed using Stata version 14.2 (StataCorp, College Station, TX, USA).
Ethical Considerations
This present study was conducted in accordance with the principles outlined in the Declaration of Helsinki and approved by the Institutional Review Board of Chi Mei Medical Center (IRB No.11208–009). As this was a retrospective analysis of previously collected data, the requirement for informed consent was waived by the IRB. All data were de-identified prior to analysis to protect patient confidentiality.
Results
A total of 897 patients were identified with TIA or acute ischemic stroke during the study period. After excluding individuals with in-hospital strokes, death at discharge, those without admission, and those discharged against medical advice, 754 eligible patients were classified into Group I (50%), Group II (21%), and Group III (29%) (Figure 1).
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Figure 1 Flowchart of patient selection in this study. Values of bold N indicate the number of patients initially screened, included in the final analysis, and in each discharge mRS group.
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Patient with poorer discharge functional status tended to have older age, greater stroke severity, longer hospital stays, and a higher prevalence of comorbidities and vascular risk factors including hypertension, atrial fibrillation, ischemic heart disease, previous stroke history, and end-stage renal disease requiring dialysis (Table 1). Analysis of stroke subtypes according to the TOAST criteria revealed higher proportions of large artery atherosclerosis and cardio-embolism in Groups II and III compared to Group I, with more patients in the former groups receiving acute reperfusion therapy. Discharge disposition varied significantly, with approximately 96% of Group I patients returning home compared to around 60% in Group II and one third in Group III. The PAC program was predominantly utilized by patients not returning home in Group II, and by a third of patients in Group III, with the remainder of Group III transitioning to nursing institutions or other hospitals. Overall, clinical adherence to continuous care post-discharge remained high, with interruption of medical care or loss to follow-up ranging from 2% to 4% across the groups. Patients in Groups II and III were more likely to opt for home-care services provided by LTC 2.0 with 14% each.
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Table 1 Clinical Characteristicsa in 754 Patients with TIA/Acute Ischemic Stroke Stratified by Discharge Functional Statusb
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Functional status 3 months after stroke onset is depicted in Figure 2. Approximately 90% of Group I patients maintained a favorable functional status (mRS 0–2), while nearly half of Group II and 30% of Group III demonstrated improvement, achieving either mRS 0–2 or mRS 3 (Supplementary Table 1). Among patients in Group II (10%) and Group III (57%) with nasogastric tube or urinary catheter indwelling at discharge, about two-thirds had these devices successfully removed by 3 month (Table 2). Readmissions within 3 months post-stroke were more prevalent in Group III, and the reasons for readmission varied significantly among the three groups. Recurrent stroke and cardiovascular events were more common in Group I and II, and infections were predominant in Groups II and III (Table 3). A portion of readmissions, mainly in Group I, were classified as “Others”, which generally reflected scheduled surgery, routine or planned care and other non-stroke-related causes.
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Table 2 Medical Tube Indwelling a at Discharge and Proportions of Successful Removal at 3 months After Stroke Onset Stratified by Discharge Functional Status b
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Table 3 Re-Admissions a Within 3 months After Stroke Onset Stratified by Discharge Functional Status b
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Figure 2 The 3-month functional outcomes in 754 patients with TIA/acute ischemic stroke stratified by discharge functional state*. Abbreviation: mRS, modified Rankin Scale. Notes: *Subjects were grouped by the discharged modified Rankin Scale as Group (I) 0–2, Group II: 3, and Group III: 4–5.
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A total of 142 patients attended the PAC program with 11 patients in Group I, 58 in Group II and 73 in Group III. Regardless of the groups, patients who participated in the PAC program demonstrated a comparable functional improvement rate of approximately 50% at 3 months post-stroke onset. On the contrary, patients who were sent to nursing institutions showed limited improvement, especially among Group II and Group III (Table 4).
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Table 4 Functional Improvement a at 3 months Stratified by Discharge Functional State b and Discharge Disposition
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Discussion
In light of Taiwan’s aging population and shortage of family caregivers, the government has introduced several programs to strengthen post-stroke care. Notably, the PAC-CVD program provides short-term intensive rehabilitation at home and in community hospitals, while the LTC 2.0 provides integrated community services for long-term support, including home-based care and reablement strategies. These initiatives aim to enhance continuity of care, improve patient function, and reduce disability after discharge. Our findings suggest that these services play a critical role in bridging care gaps and should be further promoted to support stroke survivors’ recovery and quality of life.
This single-center observation study analyzed the post-stroke recovery trajectories of patients with varying levels of disability at three months after onset of stroke. We specifically evaluated the utilization patterns and outcomes associated with different discharge planning strategies, including outpatient follow-up, PAC-CVD, and LTC 2.0 services. The results provide valuable insight into how transitional care models are currently implemented in practice and highlight opportunities for optimizing continuity of care across different levels of disability.
In our study on post-discharge transitional care, the majority of patients, up to 90%, with mild disabilities (Group I) received standard outpatient follow-up care at our institution. For patients with moderate disabilities (Group II), 37% were transferred to PAC programs upon discharge, and ultimately, around 80% of all patients in Group II transitioned to our outpatient care. As for patients with severe disabilities (Group III), approximately one-third received PAC program, one-third returned home for care, and one-third were transferred to nursing institutions. Following these transitions, 17% went on with home-based medical care, while 60% continued with outpatient medical care.
A total of 142 patients in our study participate in the PAC program after discharge. Among these patients, 48% from Group II and 51% from Group III had functional improvements at 3 months. Additionally, only 27% of patients had severe disability (mRS 4–5) 3 months post-stroke. Based on these findings, we observed that even patients with moderate to severe disabilities who received proactive rehabilitation through PAC programs demonstrated positive clinical outcomes. This highlights the PAC program as a commendable transitional medical service for post-discharge care.
The high success rate of removing nasogastric tube and urine catheter in our study indicates that the care assessment at three months post-stroke was effective. However, infection remains the leading cause for hospital readmissions, especially among patients with moderate to severe disabilities, highlighting the need for further consideration and improvement in patient care.14,15 For instance, enhancing rehabilitation to avoid prolonged bedridden status or frequent falls, implementing swallowing training and food preparation to reduce choking, conducting bladder training to prevent residual or cloudy urine and lower the risk of urinary tract infections, and maintain personal and environmental hygiene to avoid skin infections, among other measures. Therefore, upon discharge, efforts should focus on enhancing home care capabilities and coordinating LTC 2.0 care integration.
In addition, it is noteworthy that patients in Group I and II showed fairly good medical adherence, with a high 96–97% rate at 3 months after stroke event. However, recurrent stroke and cardiovascular events remained one of the primary reasons for readmission, indicating the importance of establishing clear treatment targets and stringent monitoring during medical follow-ups. This may include monitoring drug compliances, controlling blood pressure and serum sugar level to ideal thresholds, among other measures.
In a previous study analyzing data from the NINDS-tPA trials, discharge destinations were home in 42.1%, rehabilitation in 33.0%, skilled nursing facility in 9.8%, and in hospital-death in 12.4%.16 The study also identified a strong correlation between discharge destination and 3-month mRS (R=0.71, P<0.0001). In our cohort, a higher percentage (69%) of patients returned home, while the percentage sent to skilled nursing institutions was similar. This higher home-discharge rate may reflect differences in healthcare systems and accessibility. In Taiwan, the high accessibility of outpatient clinics, home-based medical services, and widely available rehabilitation programs under the coverage of National Health Insurance likely facilitate earlier and safer discharge to home. Cultural factors and strong family support may also contribute to the preference for home discharge compared with international cohorts. A similar correlation between discharge destination and functional outcome was observed in our study. Patients who returned home had a high percentage (73%) of good functional outcomes at 3 months post stroke event, whereas patients discharged to skilled nursing facilities had a high percentage (75%) of severe disability. Further analysis based on discharge disability levels showed that among patients with moderate to severe disability, those receiving outpatient follow-up or post-acute care (PAC) had higher rates of functional improvement at 3 months. In contrast, patients receiving home-based medical care or transferred to nursing institutions exhibited lower rates of improvement.
In addition to the NINDS-tPA trials, multiple other studies have highlighted the correlation between discharge destination and post-stroke outcomes. Springer et al reported that stroke survivors with the lowest functional status who were discharged to skilled nursing facilities had significantly higher 1-year mortality compared with those discharged to inpatient rehabilitation facilities (64% vs 29.6%).17 Man et al also found that stroke survivors discharged home had a 30-day readmission rate of 8.6%, whereas those discharged to skilled nursing facilities experienced a higher rate of 13.2%.18 These findings, along with our study, reinforce the importance of structured rehabilitation and coordinated care in promoting recovery among stroke survivors.
This real-world, observational study, descriptively analyzes 3-month functional outcomes in acute ischemic stroke patients discharged from a tertiary medical center in Taiwan. It outlines the current landscape of our transitional care system and the utilization patterns of various health care services. There are several limitations to this study, including its retrospective design, modest sample size, and incomplete discussion of some important confounding factors such as stroke types, baseline functional status, and medication use. The observational nature also limits causal inference, and single-center data may restrict generalizability. Nonetheless, the results of this study remain highly relevant to our daily clinical practices.
Conclusion
Based on the results of this observational study, we recommend encouraging post-acute care (PAC) to enhance recovery for stroke patients with disabilities. For patients with moderate to severe disabilities, discharge planning should incorporate their specific care needs and facilitate rapid access to care resources provided by the LTC 2.0. Finally, monitoring medication adherence and assessing cardiovascular risk factors regularly should be part of medical management for all patients to achieve optimal health outcomes.
Artificial Intelligence Use Statement
Artificial intelligence tool Open AI’s ChatGPT was used solely for improving grammar, clarity, and structure during the manuscript preparation. The authors reviewed and verified all contents to ensure its accuracy and integrity. No AI tools were used to generate original data or perform data analysis.
Acknowledgments
We would like to express our gratitude to Chi Mei Stroke Center for providing the data and facilities, as well as for offering invaluable guidance and insights during the manuscript preparation.
Disclosure
The authors report no conflicts of interest in this work.
References
1. Ho JP, Powers WJ. Contemporary management of acute ischemic stroke. Annu Rev Med. 2025;76(1):417–429. doi:10.1146/annurev-med-050823-094312
2. Gittler M, Davis AM. Guidelines for adult stroke rehabilitation and recovery. JAMA. 2018;319(8):820–821. doi:10.1001/jama.2017.22036
3. Xian Y, Li S, Jiang T, et al. Twenty years of sustained improvement in quality of care and outcomes for patients hospitalized with stroke or transient ischemic attack: data from the get with the guidelines-stroke program. Stroke. 2024;55(11):2599–2610. doi:10.1161/STROKEAHA.124.048174
4. Barlinn K, Winzer S, Helbig U, et al. Case management-based post-stroke care for patients with acute stroke and TIA (SOS-Care): a prospective cohort study. J Neurol. 2024;271(8):5333–5342. doi:10.1007/s00415-024-12387-0
5. Dalli LL, Andrew NE, Kim J, et al; PRECISE investigators. Understanding of medications and associations with adherence, unmet needs, and perceived control of risk factors at two years post-stroke. Res Social Adm Pharm. 2022;18(9):3542–3549. doi:10.1016/j.sapharm.2022.01.007
6. Sui W, Wan LH. Association between patient activation and medication adherence in patients with stroke: a cross-sectional study. Front Neurol. 2021;12:722711. doi:10.3389/fneur.2021.722711
7. Hsieh CY, Tsao WC, Lin RT, Chao AC. Three years of the nationwide post-acute stroke care program in Taiwan. J Chin Med Assoc. 2018;81(1):87–88. doi:10.1016/j.jcma.2017.09.003
8. Chen TP, Lin YJ, Wang YL, Wu LM, Ho CH. Impact of interprofessional collaborative practice on functional improvements among post-acute stroke survivors: a retrospective cross-sectional study. J Multidiscip Healthc. 2024;17:3945–3956. doi:10.2147/JMDH.S467777
9. Chu CL, Chen YP, Chen CCP, et al. Functional recovery patterns of hemorrhagic and ischemic stroke patients under post-acute care rehabilitation program. Neuropsychiatr Dis Treat. 2020;16:1975–1985. doi:10.2147/NDT.S253700
10. Chiu TY, Yu HW, Goto R, et al. From fragmentation toward integration: a preliminary study of a new long-term care policy in a fast-aging country. BMC Geriatr. 2019;19(1):159. doi:10.1186/s12877-019-1172-5
11. Hsu HC, Chen CT. LTC 2.0: the 2017 reform of home-and community-based long-term care in Taiwan. Health Policy. 2019;123(10):912–916. doi:10.1016/j.healthpol.2019.08.004
12. Chen CF, Fu TH. Policies and transformation of long-term care system in Taiwan. Ann Geriatr Med Res. 2020;24(3):187–194. doi:10.4235/agmr.20.0038
13. Hsieh FI, Lien LM, Chen ST, et al. Taiwan stroke registry investigators. get with the guidelines-stroke performance indicators: surveillance of stroke care in the Taiwan stroke registry: get with the guidelines-stroke in Taiwan. Circulation. 2010;122(11):1116–1123. doi:10.1161/CIRCULATIONAHA.110.936526
14. Qiu X, Xue X, Xu R, et al. Predictors, causes and outcome of 30-day readmission among acute ischemic stroke. Neurol Res. 2021;43(1):9–14. doi:10.1080/01616412.2020.1815954
15. Abreu P, Magalhães R, Baptista D, Azevedo E, Silva MC, Correia M. Readmissions and mortality during the first year after stroke-data from a population-based incidence study. Front Neurol. 2020;11:636. doi:10.3389/fneur.2020.00636
16. Zhang Q, Yang Y, Saver JL. Discharge destination after acute hospitalization strongly predicts three month disability outcome in ischemic stroke. Restor Neurol Neurosci. 2015;33(5):771–775. doi:10.3233/RNN-150531
17. Springer MV, Skolarus LE, Feng C, Burke JF. Functional impairment and postacute care discharge setting may be useful for stroke survival prognostication. J Am Heart Assoc. 2022;11(6):e024327. doi:10.1161/JAHA.121.024327
18. Man S, Bruckman D, Tang AS, Uchino K, Schold JD. The association of socioeconomic status and discharge destination with 30-day readmission after ischemic stroke. J Stroke Cerebrovasc Dis. 2021;30(12):106146. doi:10.1016/j.jstrokecerebrovasdis.2021.106146