3. Integrated Stroke Planning, Transitions of Care and Communication

Notes

Successful integrated care requires interdisciplinary communication, coordination, and comprehensive planning with the individual, caregivers, and supports. Working together creates a shared accountability as the individual with stroke moves across transitions of care and care settings. (https://www.who.int/)
When gaps occur in care transitions, individuals are susceptible to fragmentation in care, delayed care, poor quality of care, unfavorable experiences, compromised safety, and adverse medical events. https://cihr.ca/
Individualized assessment and care planning in stroke refers to a tailored approach that focuses on the unique needs, preferences, and goals of each individual recovering from a stroke.
This module focuses on two types of transitions: 1) transition from one healthcare provider/team/setting to another (e.g., acute inpatient care to inpatient rehabilitation; repatriation to a different acute care hospital); 2) transition to community-based setting (e.g., return home with or without homecare support services; to long-term care or assisted living).
Refer to Introduction- Definitions and Descriptions section for additional information.

Refer to Box 3 in this section for a Checklist of Core Transition Summary Information and CSBPR Rehabilitation and Recovery following Stroke publication: Part One.⁸

Recommendations and/or Clinical Considerations

3.0 General Principles of Integrated Stroke Care

Integrated care planning and effective communication are essential in stroke care and should be part of all stroke care planning and delivery to address individual needs, promote continuity of care, safety, optimal recovery, shared decision-making, and reduce the risk of complications and adverse events at all transition points [Strong recommendation; Moderate quality of evidence].
Integrated care and transitions of care are the responsibility of all members of the designated interdisciplinary stroke team. Roles among the team should be clarified to ensure lines of responsibility related to managing transitions and eliminating potential gaps in care [Strong recommendation; Moderate quality of evidence].
The interdisciplinary team should actively engage the individual with stroke, family members and caregivers to review and update the care plan, and to discuss progress, concerns and transition planning [Strong recommendation; Moderate quality of evidence].
1. This should occur regularly and should be updated to reflect changes in functional or medical status [Strong recommendation, Low quality of evidence].
2. Virtual modalities to support participation may be considered [Strong recommendation, Low quality of evidence].
The following components of effective and integrated transitions should be considered for individuals with stroke:
1. A comprehensive assessment of the individual with stroke’s medical history, physical and cognitive abilities, emotional well-being, cultural and linguistic needs, environmental and social circumstances [Strong recommendation; Moderate quality of evidence].
2. A goal-oriented transition plan should be developed and revised with the individual with stroke, family, and caregivers [Strong recommendation; Moderate quality of evidence].
3. Interdisciplinary communication and care coordination with shared responsibility for timely transfer of information, support for transitions, and ensuring continuity in development and implementation of individual plans of care [Strong recommendation; Moderate quality of evidence].
4. Inclusion of transition planning and processes into routine workflows, with clear allocation of roles and responsibilities for members of the interdisciplinary team for successful transitions of care across all stages and settings [Strong recommendation; Moderate quality of evidence].
5. Effective processes and adequate resources to ensure timely transitions within evidence-based benchmarks, and built-in flexibility for individuals to re-access care or adapt individual care plans as circumstances evolve [Strong recommendation; Moderate quality of evidence].
6. Structured tools and processes to ensure seamless transfer of information between transition points and teams of providers [Strong recommendation; Low quality of evidence].
7. Protocols that enable rapid assessment and provision of all medications, equipment, aids (including communication aids) and structural adaptations needed by individuals with stroke to facilitate smooth and timely transitions [Strong recommendation; Low quality of evidence].
8. Education to build skills and competency among stroke team members to ensure the transition needs of individuals with stroke and their families are met across the continuum of care, in a variety of settings [Strong recommendation; Moderate quality of evidence].
9. Education to build skills and competency among individuals with stroke and their family on an ongoing basis [Strong recommendation; Moderate quality of evidence]. Refer to Section 5 of this module for additional information.
10. Access to a designated contact person (such as a navigator role) who is able to provide ongoing support, access to community resources and initiation of re-assessments by healthcare providers as needed (e.g., home care services, access to primary care physician, driving assessments) [Strong recommendation; Moderate quality of evidence].
11. Assessment of caregiver ability to meet the specific needs of the individual with stroke [Strong recommendation; Low quality of evidence]. Refer to CSBPR Rehabilitation, Recovery and Community Participation following Stroke Module: Part One, Sections 7, 8 and 9 for for additional information.⁸
12. Optimal use of current and emerging technology to access care, resources and information along the continuum of care [Strong recommendation; Moderate quality of evidence]. Refer to CSBPR Virtual Stroke Care Implementation Toolkit for additional information.⁷⁵
13. Functional integrated electronic medical records (EMRs) across the continuum of care with access for all healthcare providers involved in stroke care, and access for individuals with stroke [Strong recommendation; Moderate quality of evidence].
14. Robust data collection mechanisms to monitor quality of care and performance against benchmarks, with processes in place to review data and integrate improvements into ongoing care delivery [Strong recommendation; Moderate quality of evidence]. Note, each set of recommendations across the CSBPR suite of modules also includes a set of specific structure, process, outcome and patient-oriented performance measures to support quality monitoring and improvement.
Stroke clinicians should support individuals with stroke to actively participate in decision-making about their care, ideally by using evidence-based decision support tools in preparation for, and during consultations to facilitate the shared decision-making process [Strong recommendation; Moderate quality of evidence].
The health care team should review care plans with the individual with stroke, and their family at least weekly and at transition points, updating the care plan to reflect changing needs, which may include evolving needs and goals, progress through recovery and changes in health status [Strong recommendation; Moderate quality of evidence].
Family meetings with the integrated care team should be considered to discuss the care plan, treatments, and other relevant information to support person and family-centred care and transitions of care [Strong recommendation; Moderate quality of evidence].
Mechanisms should be in place to promote continuity of care between healthcare facilities and services, such as between acute care facilities, rehabilitation, prevention, primary care, community-based services, long-term care, the individual with stroke, their family and caregivers [Strong recommendation; Moderate quality of evidence].
Individuals with stroke, their family and caregivers should be provided with sufficient information about which services are available and how to access them at all stages of the pathway of care. All information should be provided in a format accessible to those with communication disabilities [Strong recommendation; Moderate quality of evidence].

Section 3.0 Clinical Considerations

Individuals at risk of suboptimal transitions may include populations disproportionately impacted by inequities such as Indigenous peoples, newcomers to Canada, gender diverse individuals, residents from remote and rural locations, unhoused individuals, and older adults.
The individual 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 individual progresses through transitions along the continuum of care.

3.1 Transitions across the Stroke Care Continuum

Transition discussions, decisions, and activities should occur as soon as possible and throughout the care and recovery process to reflect changing and evolving needs, goals, and progress of the individual with stroke [Strong recommendation; Low quality of evidence].
The following should be considered throughout transition planning:
1. Members of the healthcare team should manage expectations regarding discharge or transfer dates and communicate in a timely manner with individuals with stroke and their family [Strong recommendation; Low quality of evidence].
2. Potential issues that may delay discharge/transition for the individual with stroke and their family should be identified early and mitigated [Strong recommendation; Moderate quality of evidence].
3. Referrals and/or appointments should be arranged prior to the individual with stroke leaving their current setting, especially short stay settings including emergency department and acute care for those discharged directly back to the community [Strong recommendation; Low quality of evidence].
4. Virtual care modalities should be used where appropriate to facilitate transition planning and increase access to timely and optimal stroke care follow-up [Strong recommendation; Moderate quality of evidence]. Refer to CSBPR Virtual Stroke Care Implementation Toolkit for additional information. ⁷⁵
Specific transition planning activities that should be completed include:
1. Provide written and verbal discharge instructions with demonstrations of skills as needed to the individual with stroke, their family and caregivers. Ensure instructions are tailored to their needs and characteristics (communication, culture, cognition, sensory - including hearing and vision, and health literacy) [Strong recommendation; Moderate quality of evidence]. Refer to Clinical Consideration 1 and Section 5 and Section 6 for additional information. Refer to the CSBPR Rehabilitation, Recovery and Community Participation Following Stroke, Part One: Stroke Rehabilitation Planning for Optimal Care Delivery (2025) for additional information.⁸
2. A post-discharge follow-up plan should be initiated by designated team members before discharge from the current or referring site and at the receiving site to ensure continuity of care [Strong recommendation; Moderate quality of evidence].

Section 3.1 Clinical Considerations

When providing instructions at care transitions, healthcare team members should address the following:
1. Any risks and safety considerations relevant to the individual’s recovery;
2. Clear individualized instructions and tailored resources to support the recovery process;
3. Medications education including instructions for use, indications for use, duration of treatment, any adjustments, renewals and clarity on who will provide ongoing medication management;
4. Details of follow-up care and appointments and contact information for follow-up care providers;
5. A designated point of contact for any questions or concerns.

3.2 Health Management Following Stroke

All individuals with stroke who transition across settings should be assessed for mobility, activities of daily living (ADL) and instrumental ADL (IADL) prior to discharge (including a community skills evaluation and home assessment as needed) [Strong recommendation; Moderate quality of evidence].
Individuals living in the community following stroke should have access to regular and ongoing healthcare follow-up appropriate to their specific needs, which may address evaluating progress of recovery, preventing deterioration, maximizing functional and psychosocial outcomes, preventing stroke recurrence, and improving quality of life [Strong recommendation; Moderate quality of evidence].
1. Initial review with primary care providers would ideally occur within the first month following hospital discharge and address key factors in secondary prevention, medical and functional issues, and establish cadence for ongoing follow-up as required [Strong recommendation; Low quality of evidence]. Refer to CSBPR Secondary Prevention of Stroke module ⁶ for additional information and the CSBPR Post-Stroke Checklist.
Individuals with stroke living in the community who experience a decline in functional status should have access to additional rehabilitation therapy and receive targeted interventions as appropriate [Strong recommendation; Moderate quality of evidence] even if the change occurs many months/years post-stroke. Refer to CSBPR Rehabilitation, Recovery and Community Participation following Stroke module: Part Two: Delivery of Stroke Rehabilitation to Optimize Functional Recovery for additional information. ⁷⁶
Processes should be in place for individuals following a stroke to re-access rehabilitation, secondary prevention services, or other supports and services as required during longer-term recovery [Strong recommendation; Moderate quality of evidence].
Individuals with stroke or TIA should be screened for any changes in cognition following stroke at transition points and when there is a change in health status [Strong recommendation; Moderate quality of evidence]. Note, changes can be reported by the individual, family members, caregivers or clinicians. Refer to CSBPR Vascular Cognitive Impairment module Appendix Three for more information on the presenting signs and symptoms of VCI.⁵
Individuals with stroke or TIA should be screened for any changes in mood and anxiety following stroke compared to their pre-stroke mental health status at transition points and when there is a change in health status [Strong recommendation; Moderate quality of evidence]. Refer to CSBPR Rehabilitation, Recovery and Community Participation module following Stroke: Part Three: Optimizing Activity and Community Participation following Stroke.⁹

3.3 Healthcare Provider Communication

Note: Communication may take place between healthcare providers along the continuum of care, healthcare providers and other service providers (e.g., transportation, meal services), and between healthcare providers and individuals with stroke, their family and caregivers.

All members of the interdisciplinary stroke team should share timely and up-to-date information with the individual with stroke, their family and caregivers as appropriate, and with healthcare providers at the current and next stage of care [Strong recommendation; Moderate quality of evidence].
The transferred information should be:
1. Comprehensive and timely, occur before or during transitions, and include all relevant information on the individual with stroke, their medications, and progress to date, planned appointments, ongoing recovery needs and goals [Strong recommendation; Moderate quality of evidence].
2. Coordinated transfer of information to optimize consistency of information from the interdisciplinary team to the individual with stroke, their family and caregivers [Strong recommendation; Moderate quality of evidence].
3. Provided to the primary care practitioner in a formal, detailed, discharge summary prepared by the most responsible healthcare provider [Strong recommendation; Moderate quality of evidence]. Refer to Box 3 for core content to be considered for inclusion in transition summaries.
4. Available through electronic health records that are accessible across settings and healthcare providers [Strong recommendation; Low quality of evidence].
5. Available in multiple formats including the use of virtual modalities when appropriate [Strong recommendation; Moderate quality of evidence]. Refer to Section 4. Virtual Stroke Care, and the CSBPR Virtual Stroke Care Implementation Toolkit for additional information.⁷⁵
6. A transition summary written in plain language, appropriate for aphasia and other communication issues, and culturally responsive to increase understanding, and given to the individual with stroke [Strong recommendation; Moderate quality of evidence].

Section 3.3 Clinical Considerations

Not all individuals with stroke may have a primary care provider, and if not, this should be addressed prior to discharge or transitions.

Rationale +-

Effective transition planning are critical components of high-quality stroke systems based on the principles of person-centered care given that one in 8 readmissions to hospital post stroke may be preventable. ⁷⁷ They ensure continuity, safety, and coordination of services as individuals with stroke move within and between care settings—particularly from emergency services to inpatient hospital care, rehabilitation and return to home or community care. Poorly coordinated transitions from hospital to home or other care settings are associated with increased risk of medication errors, preventable readmissions, patient dissatisfaction, and adverse events. This is particularly critical for individuals with complex health needs, such as individuals with stroke, who often require coordinated rehabilitation, follow-up care, community support, and education.

Strong interprofessional communication ensures that all team members—physicians, nurses, therapists, social workers, and primary care providers—are informed about the individual with stroke’s condition, treatment plan, goals of care, and follow-up requirements. This communication reduces fragmentation, avoids duplication of services, and ensures individuals with stroke, their family and caregivers are prepared and supported during their transition.

Discharge planning should begin early during hospitalization and involve individuals with stroke and families in shared decision-making to align care with individual needs, preferences, and social determinants of health. When healthcare teams collaborate and communicate effectively across settings, they improve patient outcomes, reduce avoidable healthcare utilization, and enhance the overall experience of care.

Individuals 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 individuals with stroke and families to share relevant information as they transition away from acute inpatient to inpatient rehabilitation settings and into the community. These concerns emphasize the importance of communication between healthcare team members and settings throughout the transitions of care.

Individuals with lived experience of stroke describe the importance of early stroke recognition and immediate connection into the stroke care system. They highlight that transition points, such as discharge from hospital or rehabilitation, can either create opportunities for connection or become moments where individuals risk falling through the cracks. They share challenges faced during transitions, including communication gaps, and emphasize the importance of clear communication between individuals with stroke, family, caregivers, and healthcare providers throughout these points and during all transition planning. Communication gaps between providers, lack of follow-up, and the absence of a clear point of contact can leave individuals and their families feeling uncertain and unsupported. They encourage the development of clear, established communication pathways to help prevent this.

Individuals with lived experience also share challenges related to lack of support, particularly when entering back into the community where they may or may not have the support of family and caregivers. They encourage thorough and detailed conversations to understand the individual’s goals and support needs when transitioning back to the community. They discuss the difficulty in re-engaging with the stroke system once no longer formally connected with a stroke care team and enthusiastically support greater access to care such as through a stroke prevention clinic. Streamlining transitions and improving communication can ensure smoother and more supportive stroke care experiences where individuals feel informed, connected and supported throughout their recovery.

System Implications +-

Integrated Stroke Planning, Transitions of Care and Communication 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:

Strong relationships and formal agreements among healthcare providers within and across regions to increase the efficient and timely transitions.
Development of processes across healthcare institutions and settings for the coordination of transitions and 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).
Resource capacity to enable appropriate and timely access to services at the next stage of care with the required specialties, intensity, and frequency.
Processes, protocols, and resources for conducting home assessments by interprofessional team members prior to discharge.
Access to self-management and caregiver training and support services as required ensuring a smooth transition.
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.
Processes in place to support data collection and reporting and integration of findings processes to monitor quality of care and performance against benchmarks.
Adequately resourced community health and support services for individuals with stroke.
Processes in place for individual to re-access stroke care or other support services as goals or function change and evolve throughout recovery.
Capacity for case management or healthcare personnel with dedicated responsibilities for discharge planning and transition support.
Staff who are aware of person’s right to privacy and who comply with privacy legislation and preferences when releasing an individual with stroke’s information.

Performance Measures +-

Transition Planning

Median length of stay of individuals with stroke in acute inpatient care (core).
Readmission rate for individuals with stroke discharged from hospital for all reasons, within 90 days, 6 months and one year.
Proportion of individuals with stroke who receive a referral to inpatient rehabilitation.
Proportion of individuals with stroke who receive a referral to outpatient rehabilitation.
Median time from acute care discharge to start of inpatient or outpatient rehabilitation services.
Proportion of individuals with stroke who receive a referral to a stroke prevention clinic at discharge from the emergency department or inpatient care.
Proportion of individuals with stroke who are discharged directly from inpatient care to long-term care.
Admission to long-term care within one year of being discharged back to the community following a stroke event.

Interprofessional Communication

Proportion of individuals with stroke 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.
Proportion of individuals with stroke 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.
Proportion of individuals with stroke who are provided a booklet or information on strategies for stroke secondary prevention.

Person-Oriented Measures (PREMS, PROMS)

Proportion of individuals with stroke who are given a copy of their completed discharge plan at the time of discharge from acute inpatient care or inpatient rehabilitation.
Proportion of individuals with stroke who return to the hospital post-discharge.
Distribution of reasons for readmission to hospital following an admission for acute stroke.
Median Modified Rankin score for individuals with stroke at time of discharge from acute care.
Quality of life of individuals after discharge for an acute stroke event, measured at transition points and routinely throughout recovery (for example, at 60, 90, 180 days and 1 year following discharge).
Proportion of individuals with stroke driving prior to their stroke and have a goal to return to driving who receive return to driving instructions prior to discharge.
Proportion of individuals with stroke who were working prior to their stroke, and have a goal to return to work, who receive vocational advice prior to discharge.

Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

Resources for Individuals with Stroke, Families and Caregivers

Summary of the Evidence +-

Evidence Table and Reference List 3

Discharge planning should begin as soon as possible during each phase of care and should involve the patient, family/caregivers, and all members of the interprofessional team. The goal of discharge planning is to ensure a safe and efficient transition between care settings while maintaining a continuity of care and coordination of services that optimize recovery and secondary prevention, as appropriate. Discharge planning activities should include a pre-discharge needs assessment, home visits, meetings between the care team, patient, and family/caregivers, a post-discharge follow-up plan, and communication with team members at the next phase of care. Johnson et al. ⁷⁸ recruited 1,239 individuals with stroke from 10 comprehensive stroke centres in Florida between 2018 and 2023, who were discharged to either home or an inpatient rehabilitation facility. The association between a composite measure of adequate transition of care (ATOC) score (range of scores 0-100%) during the first 30 days following discharge and 90-day death or readmission, was examined. Patients were discharged home (76.2%) or to inpatient rehabilitation (18.2%). 163 (13%) participants experienced the primary outcome (157 were readmitted to hospital, 3 patients died, and 3 were readmitted to hospital and died). Among patients with an ATOC score ≥75%, the risk of the primary outcome was reduced significantly. In a subgroup of 550 patients who completed a structured telephone interview at 30-day post discharge, 67% achieved an adequate ATOC score.⁷⁹

In a recent Cochrane review Gonçalves-Bradley et al. ⁸⁰ identified 33 RCTs including individual with stroke admitted to any type of hospital (acute, rehabilitation or community) with any medical or surgical condition. Among the included trials, one (Sulch et al. ⁸¹) included individual with a diagnosis of stroke. Trials evaluated discharge plans from hospital that included assessment, planning, implementation and monitoring components, initiated at some point prior to discharge. Hospital length of stay (mean difference [MD]= -0.73, 95% CI -1.33 to -0.12) and unscheduled three-month readmissions (RR=0.87, 95% CI 0.79 to 0.97) were both found to be significantly reduced for elderly patients with a medical condition who received discharge planning, compared to care as usual. No significant differences between groups were reported in terms of discharge destination or mortality. In the only RCT identified in the Cochrane review, Sulch et al. ⁸¹ 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 differences between groups were reported with respect to 6-month mortality (13% vs. 8%), institutionalization (13% vs. 21%), or length of stay (50 vs. 45). However, those randomized to receive conventional care experienced significantly greater change on the Barthel Index from 4 to 12 weeks (median change = 6 vs. 2, p<0.01) and reported significantly greater scores on the EuroQol at six-months (72 vs. 63, p<0.01). Markle-Reid et al. ⁸² randomized 90 adults, recruited from 2 outpatient rehabilitation programs in Ontario who were discharged from hospital to the community with stroke and multimorbidity (≥2 chronic conditions), with planned discharge back to the community to receive usual care (control group) or usual care plus a Transitional Care Stroke Intervention (TCSI) for 6 months. The core components of the intervention included: 1) a post-discharge telephone follow-up call within 2 days of hospital discharge by the care coordinator, 2) up to 6 virtual visits delivered by phone or videoconference by a member of the interprofessional team, lasting an average of one hour, 3) monthly team conferences in which an individualized patient-centred plan of care was developed and evaluated, 4) ongoing care coordination/system navigation support provided by the care coordinator, and 5) an online resource to support self-management and system navigation. Eleven participants were lost to follow-up. The risk of the primary outcome (hospital readmission within 6 months) was not reduced significantly in the TCSI group (3/39 vs. 5/40; RR=0.62, 95% CI 0.16- 2.40); however, there were significant group differences favouring the TCSI group on the SF-12 Physical Component Summary Score (MD=5.10, 95% CI 1.58–8.62), the Southampton Stroke Self-Management Questionnaire (MD=6.00, 95% CI 0.51–11.5), and the Person-Centred Coordinated Care Experience Questionnaire (MD=2.64, 95% CI 0.81- 4.47). There were no significant differences between groups on the SF-12 Mental Component Summary Score or the Centre for Epidemiological Studies Depression Scale 10-item tool. O’Callaghan et al.⁸³ reported significantly higher mean Barthel Index scores at 3 and 6 months in participants who were randomized to a transitional care program compared to usual care in a systematic review including 17 RCTs of persons returning home after admission to an acute or rehabilitation stroke service.

Healthcare Provider 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. ⁸⁴ A individuals with stroke 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. A systematic review authored by Mitchell et al. ⁸⁵ sought to assess the impact of co-ordinated interdisciplinary care in primary care, represented by the delivery of formal care planning by primary care teams or shared across primary-secondary teams, on outcomes in stroke, relative to usual care. The authors reported the involvement of a general practitioners (GP) was of uncertain benefit, while also noting that few studies described the tasks and roles GPs. In a systematic review, Kattel et al. ⁸⁶ included 19 studies which described hospital discharge communication between hospital-based providers and primary care physicians (PCPs). While a median of 55.1% of hospital discharge communications were transferred to the PCP within 48 hours, 8.5% of discharge summaries never reached the PCP. Information that was absent from discharge summaries included diagnostic test results (61%), pending tests at discharge (25%), and follow-up plans (41%). PCP received notification of discharge in only 23% of cases. In a controlled study of 3,248 hospitals, Mitchell 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. ⁸⁷ 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. ⁸⁸ 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. ⁸⁹ 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.

Sex & Gender Considerations

Sex and gender differences may play a role in interprofessional communication across healthcare settings, influencing team dynamics, collaboration, and patient care; however, the topic has not been well researched within interdisciplinary teams. In a qualitative study of operating room personnel in Ontario ⁹⁰ traditional gender roles, norms and stereotypes were reported by both men and women, with potentially negative consequences including a breakdown in communication, and poor team morale.