Discharge planning should be initiated as soon as possible after the patient is admitted to hospital (emergency department or inpatient care) [Evidence Level B].
- A process should be established to ensure that patients, families and caregivers are involved in the development of the care plan, which needs to include discharge planning [Evidence Level C].
- Discharge planning discussions should be ongoing throughout hospitalization to support a smooth transition from acute care [Evidence Level B].
- Information about discharge issues and possible needs of patients following discharge should be provided to patients and caregivers soon after admission [Evidence Level C].
- Discharge planning activities should include patient, family and team meetings, discharge and transition care plans, a pre-discharge needs assessment, caregiver training, post discharge follow-up plan, and review of patient and family psychosocial needs [Evidence Level B].
Effective discharge planning is essential for smooth transitions through the continuum of stroke care. Delayed or incomplete planning leads to prolonged hospital stays and an increased risk of adverse events following discharge. Patients, family members and healthcare providers involved in each phase of care should all be involved in discharge planning to ensure effective and safe transitions.
- Adequately resourced community health and support services for stroke patients.
- Capacity for case management or healthcare personnel with dedicated responsibilities for discharge planning.
- Protocols and pathways for stroke care along the continuum that address discharge planning throughout the stage of care.
- Strong relationships and formal agreements among healthcare providers within regions to increase the efficient and timely transition of patients.
- Processes, protocols, and resources for conducting home assessments by interprofessional team members soon after the stroke.
- Access to patient self-management and caregiver training and support services as required to ensure a smooth transition.
- Length of stay of stroke patients in acute inpatient care (core).
- Average number of alternate level of care days per stroke patient in acute care settings.
- Length of stay should be calculated as total length of stay, and then also measured against active and alternate level of care components.
- Median values should be reported for length of stay.
- Use Canadian Institute for Health Information standardized definitions and methods to calculate alternate level of care days.
Discharge planning begins early after admission to hospital for a stroke. It involves the patient, family, and the interprofessional team. The goal of discharge planning to ensure a safe and efficient transition between the acute care facility, rehabilitation, outpatient settings, primary care physician, and community while maintaining a continuity of care and coordination of services that will optimize rehabilitation potential and ensure proper secondary prevention as appropriate.216, 517, 518 Randomized trials of effective discharge planning strategies for stroke care are lacking in the literature. Observational studies and case reports suggest that effective discharge planning includes communication among team members with the patient and family, assessment of patient and family needs and preferences, an understanding of expected outcomes, and the goals for recovery and reintegration into the community. 519- 521The literature on transition management for stroke is more extensive and describe the importance and impact of communication and information transfer throughout the continuum of care in reducing adverse events and increasing the likelihood of a smooth and efficient transition (Please refer to Evidence Summary for Recommendation 6.1 for additional information.)
In a recent systematic review for all discharged patients (including stroke and other conditions), twenty-one RCTs (7234 patients) were included, with fourteen trials that recruited patients with a medical condition (4509 patients), four with a mix of medical and surgical conditions (2225 patients), one from a psychiatric hospital (343 patients), one from both a psychiatric hospital and from a general hospital (97 patients). 517Hospital length of stay and readmissions to hospital were significantly reduced for patients allocated to discharge planning (mean difference length of stay -0.91, 95% CI -1.55 to -0.27, 10 trials; readmission rates RR 0.85, 95% CI 0.74 to 0.97, 11 trials). For elderly patients with a medical condition (usually heart failure) there was insufficient evidence for a difference in mortality (RR 1.04, 95% CI 0.74 to 1.46, four trials) or being discharged from hospital to home (RR 1.03, 95% CI 0.93 to 1.14, two trials). This was also the case for trials recruiting patients recovering from surgery and a mix of medical and surgical conditions. In three trials patients allocated to discharge planning reported increased satisfaction. The reviewers concluded that a structured discharge plan tailored to the individual patient probably brings about small reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition.
A cross-sectional qualitative study by Almborg and colleagues (2008) explored patients’ perceptions of participation in discharge planning using a patient questionnaire.519The interviews revealed that 72-90 percent of patients perceived involvement in information sharing, 29-38 percent with regards to medical treatments and 15-47 percent reported they were involved in discussions about goals and needs.