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.
Health care surveillance data indicates that stroke patients are among the largest patient population receiving long-term care, and their number is steadily increasing worldwide. This transition often involves emotional concerns for patients, families and caregivers that are not necessarily experienced with other transitions. Stroke patients who transition to long-term care should be cared for in an environment that is supportive, with staff knowledgeable and competent in meeting the specific needs of stroke patients and their families within this setting. This will enable the stroke survivor to maintain quality of life and dignity, and have rehabilitation and recovery goals and plans that focus on restorative care, maintenance of function, support for health declines, and sensitivity to family needs. The post-discharge period is consistently reported by stroke survivors and their families to be a stressful and challenging time as they adjust to new roles, altered functional and cognitive abilities, and changes in living setting for patients admitted to long-term care following an acute stroke.
Successful transition to long-term care for patients, families, and caregivers requires:
- Processes to support timely and efficient transfer from acute care to long term care, avoiding multiple transfers before reaching planned destination.
- Adequate follow-up by care providers in all provinces and territories to support ongoing access to rehabilitation services for stroke survivors allowing transition to long-term care settings.
- Assistance for patients, families, and caregivers with an evolving care plan and regular follow-up assessments.
- Communication strategies and processes to ensure timely sharing of information across all healthcare providers, including between long-term care team and community/hospital healthcare teams.
- Programs that support timely and affordable access to mobility and other assistive devices for patients with stroke in long-term care.
- Ongoing stroke specific education and training for healthcare professionals and caregivers in the community and long-term care settings to increase stroke care expertise.Â Training to be provided by a range of healthcare disciplines, such as physiotherapy, occupational therapy, speech language pathology, and dietitians.
- Strategies and services to assist stroke survivors to maintain, enhance, and develop appropriate social support, and to re-engage in desired social, and recreational activities.
- Proportion of patients who are discharged from acute care directly to a long-term care setting following an acute stroke.
- Proportion of stroke patients who were living independently (e.g., at home) prior to stroke who are admitted to long-term care following stroke.
- Proportion of readmissions to acute care for stroke-related causes following discharge to long-term care, stratified by type of stroke.
- Changes in functional status from time of admission compared at 3 months, 6 months and one year following admission to long-term care.
- Number of visits to an emergency department within 3 months, 6 months and one year following admission to long-term care, stratified by reason for visit or hospital admission.
- Measure of burden of care for family and caregivers of stroke survivors living in the community, and change in burden scores from before long-term care admission, and at 3 months, 6 months and one year following admission to long-term care.
- The Canadian Institute for Health Information holds an administrative data set for complex continuing care and long term care, which uses a minimal data set that is mandated in several regions across Canada. This data set uses the Resident Assessment Instrument tool for assessing functional status. At this time there are no validated comparison models between the Functional Impact Measure and the Resident Assessment Instrument.
- Hospital readmissions from inpatient rehabilitation to acute care can be obtained from hospital administrative data nationally and provincially.
Health Care Provider Information
- Table 1: Tools to Assess Participation and Health-Related Quality of Life
- Registered Nurses’ Association of Ontario: Long-Term Care Best Practices Initiative
- Registered Nurses’ Association of Ontario: Positioning Techniques in Long-Term Care
- The Functional Independence Measure (FIM®)
- The Chedoke-McMaster Stroke Assessment
- Taking Charge of Your Stroke Recovery
- Your Stroke Journey: A guide for people living with stroke
- Post-Stroke Checklist
- HSF Stroke Resources Directory
- Life After Stroke
- Getting on with the Rest of Your Life after Stroke
- Deciding on Long-Term Care
- Preparing For the Move Into Long-Term Care; “A Checklist”
Following a stroke event, high levels of disability may warrant admission to a long term care institution. Independent predictors of discharge to a nursing home have been identified and include increasing age, increasing dependency for ADLs and absence of availability of a caregiver (Pereira et al. 2014, Brodaty et al. 2010, Portelli et al. 2005). The numbers of patients admitted to a long-term care facility, both immediately upon discharge from hospitals, and up to 10 years post stroke have been examined. At one month following discharge from hospital, Chuang et al. (2005) reported that of 714 patients admitted to hospital following stroke, 1 month after discharge 4.5% of patients had died and 10.4% had been admitted to a LTC facility. Brodaty et al. (2010) followed 202 participants, mean age of 72 years, without dementia who had suffered an ischemic stroke. Among those who survived, nursing home admission rates were 24% at 5 years and 32% at 10 years. Walsh et al. (2008) reported that among a group of 136 patients admitted to a stroke unit of a single hospital (median age was 77 years), 40.3% of patients were institutionalized at 4 years.
Patients discharged to long term care require discharge planning much like individuals returning to their own homes. Several studies have examined factors for effective discharge communication between inpatient hospital care and institutional care facilities. Clear communication between facilities regarding nutritional needs, functional status, communication abilities, risk assessment, and medical management is necessary for an optimal transition. (Sackley & Pound 2002; Sackley & Pound 2002).
Individuals residing in skilled nursing facilities with staff trained in stroke management, and who have access to post stroke therapy resources, may experience better quality of life. In a study (Brajkovic 2009) examining individuals living in a nursing home who received 24 hour care including access to psychiatric care, physician visits, daily physiotherapy, and weekly massage services, nursing home residents experienced greater quality of physical, psychological, social, and environmental quality of life scores compared with individuals living in their own homes receiving many of the same services. Individuals residing in nursing homes also experienced better perceived quality of life and health status than their residentially residing counterparts.