3.0 Interprofessional care planning and effective communication is essential to ensure continuity of care, safety, and to reduce risk of complications and adverse events during stroke care particularly at transition points [Evidence Level C].
3.1 Individualized Care Plan
The person with stroke, their family and caregivers should be actively engaged in development of an up-to-date care plan:
- The care plan should be person-centered; culturally appropriate; include person-centered goals;and defines ongoing individualized care needs [Evidence Level C].
- The care plan should be reviewed with the person with stroke and updated to reflect changing needs, evolving goals, progress at each transition, when changes and/or improvements in health status occur and when the person is not progressing in recovery. [Evidence Level B].
3.1 Clinical Consideration:
- The care plan should be initiated at the first point of contact with the healthcare system, such as the emergency department, and be refined and updated as the person progresses through the continuum of care.
3.2 Transition planning
Transition planning should begin as soon as possible following initiation of care at each applicable stage and setting [Evidence Level B].
- Transition planning discussions, decisions, and activities should be ongoing to reflect changing needs, evolving goals, and progress through the recovery process [Evidence Level B].
- A transition planning process should be established as a well-organized collaboration between health professionals, the person with stroke, their family, and caregivers [Evidence Level B].
- The following should be considered throughout transition planning:
- Formulation of a goal-oriented transition plan (e.g., discharge date) with the person with stroke, family, and caregivers [Evidence Level B].
- Identification of possible transition issues for the person with stroke and their family, and other needs which could potentially delay discharge. These should be addressed early in transition planning [Evidence Level B].
- Assessment of caregiver capacity, decision-making ability, and ability to meet the physical and psychosocial needs of the person with stroke [Evidence Level C]. Refer to Section 1 and Section 2 for additional information.
- Addressing transition planning needs and booking of appointments prior to leaving current setting, especially short stay settings including emergency department and acute care for those discharged directly back to the community [Evidence Level C].
- Utilization of telemedicine modalities where available to increase access to timely and appropriate stroke care follow-up [Evidence Level B]. Refer to CSBPR Telestroke Toolkit for additional information.
- Specific transition planning activities that should be completed as appropriate include:
- A home assessment to identify home modifications required for accessibility and safety [Evidence Level B].
- Caregiver skills training specific to the current and ongoing needs of the person with stroke [Evidence Level B]. Refer to Section 1 and Section 2 for additional information..
- Planned and goal-oriented day, weekend and or overnight visits to the identified discharge location [Evidence Level B], in order to:
- help identify potential barriers,
- assess readiness for discharge,
- and to inform therapy and discharge planning activities.
- Written discharge instructions as a component of an individualized care plan that addresses the following issues as appropriate: functional ability at the time of discharge, risks and safety considerations, action plans for recovery, medications at discharge and instructions for adjustment, follow-up care, follow-up care provider contact information and information for one point of contact post-discharge [Evidence Level B].
- All communications should be available in aphasia-friendly formats as required and appropriate to the health literacy of people with stroke, their families and caregivers [ Evidence-Level B].
- A post-discharge follow-up plan, initiated by a designated team member, such as a case manager or stroke navigator, to ensure continuity of care [Evidence Level B].
3.3 Health Professional Communication
Health Professional Communication: Processes should be in place to ensure timely and effective transfer of relevant information at all points of access and transition in the healthcare system, to ensure seamless transitions and continuity of care [Evidence Level B].
- All members of the interdisciplinary stroke team should share timely and up-to-date information with healthcare providers at the next stage of care [Evidence Level B].
- The transfer of information should be:
- Comprehensive with all relevant information on the person with stroke including medications, and progress to date, planned appointments, ongoing recovery needs and goals [Evidence Level B].
- Provided to the primary care physician in a formal, typed, detailed, discharge summary (from the most responsible physician) [Evidence Level B]. Note, not all patients may have a primary care provider, and if not, this should also be addressed. Refer to Box 3 for core content to be considered for inclusion in discharge summaries.
- Timely and occur prior to the time of transition to next care setting [Evidence Level C].
- When possible, accessible through electronic health records [Evidence Level C].
- Include the use of telemedicine technology when appropriate [Evidence Level C]. Refer to CSBPR Telestroke Toolkit for additional information.
- A designated member of the team should facilitate the transfer of information and referrals to appropriate follow-up services for the person with stroke [Evidence Level B].
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
Stroke care can be complex and requires ongoing monitoring and management. Clear communication in a timely manner is essential to ensure continuity of care, safety, and to reduce risk of complications and adverse events resulting from the confusion and ambiguity that can arise during transition points.
People with a lived experience of stroke have reported that the healthcare system can seem siloed between different specialties or systems of care, with limited integration and interaction between healthcare settings or practitioners. These experiences cause frustration, feelings of being overwhelmed and add burden to families as they transition away from acute inpatient or inpatient rehabilitation settings into the community. These concerns emphasize the importance of communication between healthcare team members and settings throughout the transitions of care.
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. People with stroke, family members and healthcare providers involved in each phase of care should all be involved in discharge planning to ensure effective and safe transitions.
Using feedback provided by people with a lived experience of stroke, the importance of the timing of discharge planning was emphasized. Ensuring that the discharge planning occurs throughout the stages of care, rather than directly prior to discharge, can improve the experience of the person with stroke, their family and caregivers. Furthermore, this helps to make sure that all services and resources are established ahead of time. People with a lived experience of stroke report difficulties accessing resources post discharge relating to denial of services, for example, being unable to use a service due to an age restriction; accessing accessible transportation, and financial support. These challenges were further complicated when the person did not have a family physician, which should be addressed and taken into consideration during the discharge planning process.
Health Care Provider Information
- Taking Action for Optimal Community and Long-Term Stroke Care: A resource for healthcare providers
- Registered Nurses’ Association of Ontario Developing and Sustaining Interprofessional Health Care: Optimizing patients/clients, organizational, and system outcomes
- Health Quality Ontario – Transitioning From Hospital to Home
- Discharge Summary Outline
- Centre for Interprofessional Education (University of Toronto)
- Canadian Interprofessional Health Collaborative
- Centre for Advancement of Interprofessional Education
- Re-Engineered Discharge (RED) Toolkit
- GTA Rehab Network Inter-Organizational Transfer of Accountability Guidelines
Resources for People with Stroke, Families and Caregivers
- Taking charge of your stroke recovery: Rehabilitation and recovery infographic
- Taking charge of your stroke recovery: Transitions and community participation infographic
- Heart & Stroke Services and Resources Directory Your Stroke Journey: A guide for people living with stroke
- Post-Stroke Checklist
- A Family Guide to Pediatric Stroke
- Heart & Stroke Recovery and Support Health Information
- Stroke in Young Adults
- Talking Care of Myself: A Guide for When I Leave the Hospital
- Stroke Engine
- Canadian Partnership for Stroke Recovery Patient Resources
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.