INTERVENÇÕES DE CUIDADO TRANSICIONAL APÓS O ACIDENTE VASCULAR CEREBRAL

Abstract

INTRODUCTION: Stroke is one of the leading causes of mortality and disability worldwide, significantly impacting patients’ quality of life and burdening healthcare systems. Given the complexity of post-discharge care, transitional care interventions emerge as essential strategies to ensure continuity of assistance, reduce complications and rehospitalizations, and support effective rehabilitation. OBJECTIVE: To identify and summarize the main models and transitional care interventions applied to stroke survivors. METHOD: This is an integrative literature review based on the methodological framework of Souza, Silva, and Carvalho (2010), developed in six stages. The literature search was conducted in six international databases: MEDLINE/PubMed, CINAHL, PsycINFO, Scopus, Web of Science, and EMBASE. Studies published between 2017 and 2025 in Portuguese, English, or Spanish were included. After the screening process, 15 articles were selected for final analysis. Data collection included authorship, study type, interventions used, and key findings. RESULTS: The most frequent interventions included home visits, telephone follow-up, personalized care plans, medication review, digital platforms, and educational strategies. These interventions were mainly carried out by multidisciplinary teams, with advanced practice nurses playing a leading role. Positive outcomes included improved quality of life, greater treatment adherence, increased functionality, and higher patient and caregiver satisfaction. Only 13% of the studies reported reductions in hospital readmissions. DISCUSSION: Despite the diversity of models and the predominance of studies from high-income countries, the findings highlight the potential of transitional care to enhance post-stroke rehabilitation. However, limitations such as lack of standardization, scarcity of studies in low- and middle-income countries, and absence of cost-effectiveness analyses restrict broader implementation. The role of advanced practice nurses proved central in planning and coordinating transitional care strategies. CONCLUSION: Transitional care interventions are effective and humanized strategies for improving clinical and functional outcomes among post-stroke patients. Their successful implementation requires institutional planning, supportive public policies, adaptation to local contexts, and ongoing professional training to ensure safe, continuous, and comprehensive care.