Medicine and Health Sciences Commons^™

Care Coordination For Community Transitions For Individuals Post-Stroke Returning To Low-Resource Rural Communities, Patrick H. Kitzman, Keisha Hudson, Violet Sylvia, Frances Feltner, Johnnie Lovins

Physical Therapy Faculty Publications

High rates of hospital readmissions have been shown within 12 months post-discharge from inpatient rehabilitation following stroke. Multiple studies coupled with our previous work indicate a need for care support for stroke survivors’ transitions to the community. The Kentucky Care Coordination for Community Transitions (KC³T) program was developed to provide access to medical, social, and environmental services to support community transitions for individuals with neurological conditions and their caregivers living in Kentucky. This program assessment was conducted to determine the effectiveness of using a specially trained community health worker to support community transitions. Thirty acute stroke survivors were …