Working Together with Stroke Survivors and their Caregivers to Achieve Optimal Outcomes is imperative across stroke systems of care, and requires the participation of individuals with stroke, their families and caregivers, healthcare providers, and the broader community. The primary underpinnings of Working Together in stroke transitions of care are to provide patient and family-centered care across all transition points, and ensure effective and efficient transfers of care and information to the next stage and setting of care. Careful monitoring throughout recovery from stroke is an essential component in establishing a coordinated and seamless system of care that supports progress achieved during the initial recovery stages. In Canada, one-third of stroke patients, usually with TIA and milder strokes, are discharged back to the community directly from the emergency department. Of those patients admitted to acute inpatient care, 44% will be discharged to their homes independently, and additional 13% will be discharged home with arrangements for home care services, 16% will be transferred to an inpatient rehabilitation service, 11% will be transferred to long-term care or complex continuing care, and 13% will be transferred to another acute care facility (usually back to community hospital from a tertiary hospital) (HSFC Stroke Report 2014).
All members of the healthcare team engaged with stroke patients and families are responsible for working together to ensure successful transitions and facilitate a successful return to the community following stroke. Figure 1 depicts a pathway and steps for successful transitions, developed through an extensive consensus process (Gilmore et al, 2008).
Key components of successful transitions include:
- collaborative goal setting between the healthcare team, patients and families, where patients and family members actively participate in discussions and planning with the healthcare team and are involved in shared decision-making;
- ongoing education for patients, families and caregivers that reinforces key information and verifies understanding, regardless of setting; this includes in the emergency department, primary care, acute inpatient care (regardless of location of patient within the hospital), rehabilitation settings, outpatient and community settings;
- skills training appropriate to needs and goals of patients to facilitate safe transitions;
- discharge planning that begins soon after stroke admission and includes all relevant support services, such as home assessments and access to ambulatory and community-based rehabilitation;
- ongoing assessment of family and caregiver capacities to provide care for the patient with stroke, their individual support needs and potential burden of care;
- timely transfer of medical and recovery information between stages and settings of care;
- appropriate medical support by primary care physicians and team members, as well as stroke team members and stroke prevention services;
- stroke navigators or case managers in place to facilitate transitions of care and ensure continuity of care across settings, as well as appropriate access to needed resources and services; identification of and linkages to community resources, long term care and home-based care;
- ongoing surveillance of physical, psychological, social and emotional recovery, coping and adaptation following discharge from inpatient acute care and rehabilitation settings.
A coordinated and seamless system taking all these components into account will minimize challenges and complications for patients and families transitioning between stages and settings for stroke care, and lead to better recovery outcomes. Stroke case managers and/or stroke system navigators are valuable additions to the stroke care team, and where resources permit should be made available to patients, families and caregivers. Stroke navigators empower patients and families to be involved in their own care, build self-management skills and confidence, and aid in access to community resources, support groups and linkages. Providing supports such as navigators may reduce the burden to the health system and to health care professionals providing reactive care.
Working Together in the area of stroke care transitions is also directed to researchers and research funding organizations. The body of evidence for many of the topics addressed in this module is based on observational studies, small qualitative research initiatives and cohort studies. Randomized controlled trials and systematic reviews are lacking in this field. Despite the lower levels of evidence, the topics covered in this module have high importance for patients, families and caregivers, and are therefore presented based on moderate evidence and expert opinion.
The 2015 update of the Canadian Best Practice Recommendations Managing Stroke Transitions of Care module reinforces the growing and changing body of research evidence available to guide ongoing screening, assessment and management of patients who have experienced a stroke, families, and caregivers to ensure they move from one phase and stage of care to the next without ‘falling through the cracks’ or ‘getting lost out of the system’.
Highlights of the moderate and significant updates as well as new additions to Managing Stroke Transitions of Care module recommendations for 2015 include:
- A focus on patient-centred care, with the patient, family members and caregivers included as active members of the stroke team, being involved in decision-making, goal setting and care planning throughout the stroke care continuum;
- Recognition that stroke affects the whole family unit, and places a burden on family members; ensuring caregiver capacity, coping, and risk for depression are assessed and monitored;
- The importance of educating patients and families to understand the nature and causes of/risks for stroke, the signs and symptoms, the impact and the ongoing needs of the patient who has experienced a stroke;
- A call to action for all healthcare professionals for delivering education and support on an ongoing basis, regardless of patient location within the healthcare system, including providing new information at the right teachable time, reinforcing previously taught information, and assessing ongoing learning needs; these information needs evolve as the patient moves through the continuum of care and into longer term recovery;
- Promotion of self-management and active participation in ongoing care, adhering to rehabilitation plans and actively engaging in recovery, and following through with decisions to take prescribed medications;
- An emphasis on improving communication: between healthcare professionals and the patient, family and caregivers; and between healthcare professionals, particularly when patients are transitioning between care settings or discharged home.
The detailed methodology and explanations for each of the steps in the development and dissemination of the Canadian Stroke Best Practice Recommendations is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual available on the Canadian stroke best practices website.
Cameron JI, O’Connell CM, on behalf of the Managing Stroke Transitions of Care Writing Group. Managing Stroke Transitions of Care Module 2015. In Lindsay MP, Gubitz G, Bayley M, and Smith EE (Editors) on behalf of the Canadian Stroke Best Practices and Advisory Committee. Canadian Stroke Best Practice Recommendations, 2015; Ottawa, Ontario Canada: Heart and Stroke Foundation.
We invite comments, suggestions, and inquiries on the development and application of the Canadian Stroke Best Practice Recommendations.
Please forward comments to the Heart and Stroke Foundation’s Stroke Team at firstname.lastname@example.org
Taking Action for Optimal Community and Long-Term Stroke Care (TACLS) is an evidence-based resource closely linked with the HSF Canadian Stroke Best Practice Recommendations. It provides information and guidance to help support healthcare providers as they work together with people who have had a stroke living in community and long-term care settings. Click here for more information.
- Managing Stroke Transitions of Care guideline publication in the International Journal of Stroke
- Writing Group Members
- Figure 1: Pathways for People with Stroke to Live Fully in the Community
- Figure 2: Transitions of Care Stroke Model
- Stroke Transitions of Care Definitions
- Supporting Patients, Families and Caregivers Following Stroke
- Patient, Family and Caregiver Education
- Interprofessional Care Planning and Communication
- Community Reintegration Following Stroke
- Transition of Patient to Long-Term Care Following Stroke