Previous Section 2. Patient Family and Caregiver Education Next Section 4. Community Reintegration Following Stroke
Managing Stroke Transitions of Care

3. Interprofessional Care Planning and Communication

July 2016 - 2016 UPDATE


The Canadian Stroke Best Practice Recommendations for Stroke Rehabilitation, 5th Edition (2015) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for Managing Transitions of Care Following Stroke, and all other sections of the Stroke Rehabilitation recommendations, please click on this URL which will take you to the recommendations online in the IJS.

For the French version of these recommendations, open the appendix at this link.

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through this website, and not through the IJS.  Please click on the appropriate sections on our website below for this additional content.

Box 3: Checklist of Core Discharge Summary Information +-

Discharge Summary Check List

  • Stroke diagnosis and date of stroke
  • Secondary complications
  • Co-morbid illnesses
  • Stroke risk factors
  • Prevention strategy
  • Social and family history
  • Past medical history
  • Medications on discharge
  • Summary of hospital course
  • Physical, emotional, and cognitive status at discharge
  • Level of independence for mobility, ADLs, decision-making, including any supervision and assistance needs (driving ability if applicable)
  • Equipment and resources prescribed, including what has been provided, and what is pending
  • Recommended management plan, including therapies, home program, community activities and outstanding medical consultations
  • Ongoing and long-term patient goals
  • Follow up appointments
  • Identification of primary care provider stroke follow-up responsibilities
  • Direct communication between most responsible physician and the primary care provider
Rationale +-

Stroke patient care tends to be complex and require ongoing monitoring and management. Clear communication in a timely manner is essential to ensure continuity of care, patient safety, and to reduce risk of complications and adverse events resulting from the confusion and ambiguity that can arise during transition points.

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.

System Implications +-

Transitions of care support and actions are applicable across the continuum of stroke care, including in primary care, the emergency department, acute care, rehabilitation settings, complex care/transitional bed settings, long-term care and community settings. Processes and mechanisms should be in place in all these settings to address efficient communication between settings and healthcare providers, including:

  1. Development of processes across healthcare institutions and settings for the coordination of discharge planning and ongoing medical management through to primary care, community services, follow-up, and access to required healthcare services (e.g., ongoing rehabilitation or acute care).
  2. Processes, protocols, and resources for conducting home assessments by interprofessional team members prior to discharge.
  3. Access to patient self-management and caregiver training and support services as required ensuring a smooth transition.
  4. Resource capacity to enable appropriate and timely access to services at the next stage of care with the required specialties, intensity, and frequency.
  5. Strong relationships and formal agreements among healthcare providers within regions to increase the efficient and timely transition of patients.
  6. Implementation of standards, processes, and tools to ensure timely discharge summaries sent to primary care and other relevant healthcare professionals and/or agencies to facilitate continuity of care at transition points.
  7. Adequately resourced community health and support services for stroke patients.
  8. Providing the right care and services in the right settings at the right times following stroke.
  9. Capacity for social workers and other case management or healthcare personnel with dedicated responsibilities for discharge planning.
  10. Staff who are aware of patient/client’s right to privacy and who comply with privacy legislation and patient preferences when releasing patient/client information.
Performance Measures +-

Discharge Planning

  1. Proportion of acute stroke patients who have at least one alternate level of care day during their index acute care admission for stroke.
  2. Average number of alternate level of care days per stroke patient in acute care settings.
  3. Median length of stay of stroke patients in acute inpatient care (core).
  4. Percentage of patients who are given a copy of their completed discharge plan at the time of discharge from acute inpatient care or inpatient rehabilitation.
  5. Proportion of stroke patients who return to the hospital post-discharge for non-medical reasons (i.e., failure to cope).
  6. Readmission rate for stroke patients discharged from hospital for all reasons, within 90 days, 6 months and one year.

Interprofessional Communication

  1. Percentage of patients who are given a copy of their completed care plan and discharge summary at the time of discharge from acute inpatient care or inpatient rehabilitation.
  2. Percentage of patients for whom a discharge summary is completed prior to or within 48 hours of discharge from one care setting to the next and received by the care provider at the next stage of care.

Measurement Notes

  • 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 in hospital.
  • Interprofessional communication Performance measure 1: A copy the discharge summary should be included in acute care or inpatient rehabilitation chart, and in the chart of the primary care provider. It can be electronic or hard copy.
  • Interprofessional communication Performance measure 2: Applies at all transition points across the continuum.
Summary of the Evidence +-

Evidence Table and Reference List

Discharge Planning

In a recent Cochrane review investigating discharge planning for patients discharged from hospital, 24 RCTs, representing 8,039 patients were identified (Shepperd et al. 2013).  In most cases, trials evaluated a discharge plan either as a stand-alone intervention, or as a component of a broader intervention vs. usual care in most cases (n=19).  In a single trial (Sulch et al. 2000) the sample was restricted to discharge from hospital following a stroke. In all other studies, patients with other medical conditions were included. The use of discharge plans was associated with a significantly reduced LOS (MD -0.91; 95% CI -1.55 to -0.27) and a significant reduction in readmissions at 3 months (RR= 0.82; 95% CI 0.73 to 0.92). No significant between group differences were reported in terms of discharge destination (RR 1.03, 95% CI 0.93 to 1.14) and mortality (RR 0.99, 95% CI 0.78 to 1.25).

Within 48 hours of admission to acute care, Shyu et al. (2008) randomized 208 patient/caregiver dyads to one of 4 wards where they received a caregiver-oriented discharge planning program or routine discharge planning.  The discharge planning program was conducted by trained research nurses who evaluated caregiver needs during hospitalization and used results to guide individualized interventions, which included both health education and referral services.  Once discharged, carers were contacted within one week by telephone and two home visits were made (one week, one month) to advise and support caregivers in the home environment. Caregivers in the intervention group demonstrated significantly greater caregiver preparedness on both nursing and self-reported evaluations at discharge. At the one-month follow-up, those in the intervention group demonstrated significantly greater satisfaction with discharge needs than those in the control group. In a follow-up study (Shyu et al. 2010), the overall quality of care was reported to be significantly superior in the intervention group over the 1-year follow-up period. No significant group differences were reported with respect to self-care ability or hospital readmissions.  However, patients in the intervention group were significantly less likely to be institutionalized between 6 and 12 months post-discharge, compared to those in the control group (p<0.05).

In the only RCT identified that specifically recruited stroke patients, Sulch et al. (2000) randomized 152 patients within two-weeks of stroke onset to receive discharge planning according to an integrated care pathway or care as usual.  No significant between group differences were reported with respect to six-month mortality (13% vs. 8%), institutionalization (13% vs. 21%), or length of stay (50±19 vs. 45±23 days).  

Interprofessional Communication

Transitions between and within health care settings pose a safety and quality of care concern for patients recovering from stroke. A consensus policy statement by the American College of Physicians in 2009 highlighted concerns of patient safety at transition points, particularly between inpatient and outpatient care (Snow et al. 2009). A stroke survivor is vulnerable to many of these transition points as they progress through the acute, sub-acute and chronic stages of recovery, interacting with a range of physicians in several different health-care settings. Communication between these physicians and care settings is critical for ensuring patient safety and quality of care. In a controlled study of 3,248 hospitals, Mitchell (2015) explored the association between physician/nurse communication with the patient regarding discharge instructions and readmission. An average of 84% of patients reported receiving discharge instructions. Hospitals that had smaller bed numbers were non-profit and located in non-urban areas were more likely to provide discharge instructions. Patients reported that, on average, nurses and doctors communicated well with them 78% and 82% of the time. Controlling for other factors, increasing frequency of communication surrounding discharge instructions was associated with significantly lower number of 30-day hospital re-admissions.

Areas of communication deficits were reported in a systematic review by Kripalani et al. (2007), which included the results of 73 studies examining communication deficits between hospitals and primary care providers, and interventions to improve communication during this transition. While a median of 53% of discharge letters had arrived at the physician’s office within one week of discharge, only 14.5% of discharge summaries were received the same timeframe. However, 11% of discharge letters and 25% of discharge summaries never reached the primary care physician. Discharge letters were missing a main diagnosis in 7%-48% of cases, hospital treatment details in 22%-45% of cases, medications at discharge for 7%-48% of cases, plans for follow-up in 23%-48% of cases, and notes on patient or family counselling in 92%-97% of cases. In terms of effectiveness of interventions, a significantly higher percentage of discharge summaries that were hand delivered (compared with mailing) were received by week 4 following discharge (80% vs. 57%, p<0.001). The overall quality of the summaries was perceived to be higher and the summaries were longer when computer generated, using a standard template, and were received by the primary care physician sooner.  

Halasyamani et al. (2006) described the development of a discharge checklist, based on a literature review, expert committee and peer review, designed to identify the critical components in the process when discharging elderly patients from hospital. The final checklist includes 3 types of discharge documents: the discharge summary, patient instruction and communication on the day of discharge to the receiving care provider. Data elements included on the final checklist were: problem that precipitated hospitalization, key findings and test results, final primary and secondary diagnoses, condition at discharge (functional and cognitive), discharge destination, discharge medications, follow-up appointments, list of pending lab results and person to whom results will be sent, recommendations of sub-specialty consultants, documentation of patient education and understanding, identification of atypical problems and suggested interventions, 24/7 call-back number, identification of referring and receiving providers, resuscitation status


Stroke Resources