Text Size:   M  L  XL
Section 6.0

Transitions

This section for 2010 was created to help patients, families, and caregivers understand and move through the transitions along the continuum of stroke care. The recommendations in this section relate to particular aspects of transition management for healthcare professionals, patients, families, and caregivers.

DEFINITIONS

  • Transition refers to the movement of patients among healthcare locations, providers, different goals of care, and across the various settings where healthcare services are received.490
  • Transition management includes working with patients, families, and caregivers to establish and implement a transition plan that includes goal setting and that has the flexibility to respond to evolving needs. Successful transition management requires interprofessional collaboration between healthcare providers, clients, families, and caregivers. It encompasses the organization, coordination, education, and communication required as patients, families and caregivers move through the stages and settings for stroke treatment, recovery, reintegration, adaptation, and end-of-life care.
  • The goal of transition management is to facilitate and support seamless patient, family, and caregiver transitions across the continuum of care, and to achieve and maintain optimal adaptation, outcomes, and quality of life for the family system following a stroke. This incorporates physical, emotional, environmental, financial and social influences.

Figure 6.0:  The Canadian Stroke Strategy Model for Transitions of Care Following a Stroke

The Canadian Stroke Strategy Transitions of Stroke Care Model identifies the most common points of transition for stroke patients along the continuum of care. The arrows are presented as unidirectional for simplicity of the diagram. However, in many instances stroke patients will move back and forth between different stages or settings of care during short-term and long-term recovery and reintegration.