7. Interdisciplinary Stroke Rehabilitation Care Planning, Transitions and Communication

Note

Individualized care planning in stroke rehabilitation refers to a tailored approach that focuses on the unique needs, preferences, and goals of each individual with stroke recovering from a stroke. This process involves a comprehensive assessment of the individual with stroke’s medical history, physical abilities, emotional well-being, cultural needs, environmental and social circumstances. Through collaboration among healthcare professionals, individuals with stroke, and their families, individualized care planning aims to develop a personalized rehabilitation program that addresses specific deficits, facilitates recovery, and enhances overall quality of life. The plan is regularly reviewed and adjusted based on the individual with stroke's progress and evolving needs, ensuring that care remains relevant and effective throughout the rehabilitation experience.

Recommendations and/or Clinical Considerations

7.0 Recommendation

7.0 Interprofessional care planning and effective communication among all team members and individuals with stroke are essential and should be part of all stroke rehabilitation care planning and delivery to ensure continuity of care, safety, and to reduce risk of complications and adverse events during stroke care particularly at transition points [Strong recommendation; Low quality of evidence].

7.1 Individualized Care Plan

The individual with stroke, their family and caregivers should be actively engaged in development of a care plan, and regular updates as recovery progresses [Strong recommendation; Moderate quality of evidence].
The rehabilitation team should review the care plan with the individual with stroke at least weekly and at transition points, updating the care plan to reflect changing needs, which may include evolving goals, progress through recovery and changes in health status [Strong recommendation; Moderate quality of evidence].
Family members and caregivers should have the opportunity to meet with the rehabilitation team to discuss rehabilitation activities, progress, concerns and transition planning [Strong recommendation; Moderate level of evidence]; virtual modalities to support participation may be considered [Strong recommendation; Low quality of evidence].
A family meeting/conference to discuss the care plan, rehabilitation treatments, and other relevant information should be considered to support person and family-centred rehabilitation and transitions of care [Strong recommendation; Low quality of evidence].

Section 7.1 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.

7.2 Transition Planning

Transition planning should begin as soon as possible as a well-organized collaboration between health professionals, the individual with stroke, their family, and caregivers [Strong recommendation; Low quality of evidence].
Transition discussions, decisions, and activities should occur throughout the 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. A goal-oriented transition plan (e.g., discharge date) should be developed and revised with the individual with stroke, family, and caregivers [Strong recommendation; Moderate quality of evidence].
2. Identification of and addressing possible transition issues for the individual with stroke and their family, including those factors that may delay discharge (such as home environment concerns, unique responsibilities, social supports including caregiver engagement, transportation issues, and equipment needs) [Strong recommendation; Moderate quality of evidence]. Ideally these should be addressed early in transition planning [Strong recommendation; Low quality of evidence].
3. Referrals and/or appointments should be initiated 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. Assessment of caregiver ability to meet the specific needs of the individual with stroke [Strong recommendation; Low quality of evidence]. Refer to Section 8 and Section 9 for additional information.
5. Utilization of virtual care 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 Toolkit for additional information.
Specific transition planning activities that should be completed as appropriate include:
1. A home assessment to identify home modifications and any equipment required for accessibility and safety [Strong recommendation; Moderate quality of evidence].
2. Caregiver skills training to meet the current and changing needs of the individual with stroke [Strong recommendation; Moderate quality of evidence]. Refer to Section 8 and Section 9 for additional information.
3. Planned and goal-oriented day, weekend and/or overnight visits to the identified discharge location [Strong recommendation; Moderate quality of evidence], in order to help identify potential barriers, assess readiness for discharge, and inform therapy and discharge planning activities.
4. Written and verbal discharge instructions, with demonstrations of skills as needed, are provided to the individual with stroke and their family and tailored to their needs and characteristics (language, comprehension, culture) [Strong recommendation; Moderate quality of evidence]. Refer to Clinical Consideration 1 for additional information.
5. Verbal and written information should be tailored to the individual’s cognitive, sensory, and communication abilities and to the health literacy of the individual with stroke, their family and caregivers. [Strong recommendation; Moderate quality of evidence].
6. A post-discharge follow-up plan should be initiated pre-discharge by a designated team member to ensure continuity of care [Strong recommendation; Moderate quality of evidence].
7. Individuals with stroke should have access to designated transition support team members as needed post-discharge, such as a case manager or stroke navigator [Strong recommendation; Moderate quality of evidence].

Section 7.2 Clinical Considerations:

When providing discharge instructions, healthcare team members should address the following:
1. Any risks and safety considerations relevant to the individual’s recovery;
2. Clear individualized action and tailored resources to support the recovery process;
3. Medications at discharge, including instructions for use, any adjustments, renewals and 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 post-discharge questions or concerns.

7.3 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 [Strong recommendation; Moderate quality of evidence].
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 next stage of care [Strong recommendation; Moderate quality of evidence].
The transfer of information should be:
1. Comprehensive and timely, occur before 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. 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]. Note, not all individuals with stroke may have a primary care provider, and if not, this should also be addressed. Refer to Box 7 for core content to be considered for inclusion in discharge summaries.
3. Available through electronic health records that are accessible across settings and healthcare providers [Strong recommendation; Low quality of evidence].
4. In multiple formats including the use of virtual modalities when appropriate [Strong recommendation; Moderate quality of evidence]. Refer to Section 6 .Virtual Stroke Rehabilitation, and the CSBPR Virtual Stroke Care Toolkit for additional information.

Rationale +-

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. Currently electronic health records are not always accessible across settings for healthcare providers to follow the individual with stroke’s progression, creating risks for inconsistent and fragmented 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.

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. Individuals with stroke, family members and healthcare providers should all be involved in discharge planning to ensure effective and safe transitions, including the timing of discharge planning. Ensuring that the discharge planning occurs throughout the stages of care, rather than directly prior to discharge, can improve the experience of the individual with stroke, their family and caregivers. This helps to make sure that all services and resources are established ahead of time.

Individuals with stroke stressed the importance of home visits in discharge planning, and healthcare providers understanding of the supports available at home and in the community and the goals for recovery. They have reported difficulties accessing resources post discharge, and possible denial of services based on established access criteria; accessible transportation; and financial support. These challenges were further complicated when the individual did not have a primary care practitioner, which should be addressed and taken into consideration during the discharge planning process.

Individuals with stroke discussed the frustration and challenges that can occur if a delay between hospital discharge and beginning of outpatient/home rehabilitation is experienced. They highly appreciated receiving a written discharge document that provides information on continued rehabilitation goals, a home exercise program, as well as a list of available supports in the community that is reviewed and discussed.

Performance Measures +-

System indicators:

Proportion of healthcare organizations with electronic health records that allow individuals with stroke to access their records and information.

Process indicators:

Median number of alternate level of care days inpatient stroke rehabilitation settings.
Median length of stay of individuals with stroke in inpatient stroke 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.

Patient-oriented indicators:

Readmission rate for individuals with stroke discharged from stroke rehabilitation for all reasons, within 90 days, 6 months and one year.
Proportion of individuals with stroke who are given a copy of their completed discharge plan at the time of discharge from inpatient rehabilitation.
Proportion of individuals with stroke who return to the hospital post-discharge from inpatient rehabilitation for non-medical reasons (i.e., failure to cope, failure to thrive).
Quality of life of people 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).
Changes in functional status from discharge home from inpatient or community-based stroke rehabilitation compared at 3 months, 6 months and one year post start of rehabilitation.

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

Discharge Planning

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, individual with stroke, and family/caregivers, a post-discharge follow-up plan, and communication with team members at the next phase of care. In a recent Cochrane review, Gonçalves-Bradley et al.⁷³ identified 33 RCTs including individuals admitted to any type of hospital (acute, rehabilitation or community) with any medical or surgical condition. 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 readmission rates (relative risk [RR]=0.89, 95% CI 0.81 to 0.97) were both found to be significantly reduced for elderly individuals with a medical condition who received discharge planning, compared to care as usual. No significant between group differences were reported in terms of discharge destination or mortality. In the only RCT identified in the Cochrane review ⁷³ that included patients recovering from stroke, Sulch et al. ⁷⁴ 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 mean length of stay (days) (50±19 vs. 45±23). However, those randomized to receive conventional care experienced significantly greater improvement on the Barthel Index from 4 to 12 weeks (median change = 6 vs. 2, p<0.01) and reported significantly higher scores on the EuroQol at 6 months (72 vs. 63, p<0.01).

Stroke Navigators

Navigating through the post-stroke continuum has been highlighted as a frequent source of dissatisfaction, for individuals with stroke and informal caregivers, particularly during the transition from hospital to community. Several studies have been conducted to evaluate the benefit of individuals who coordinate access to appropriate services for individuals recovering from stroke, who go by many names including stroke navigator, case manager, care coordinator, or system navigator). Manderson et al.⁷⁵ conducted a systematic review including 15 publications, representing 9 RCTs examining system navigation models for older adults living with multiple chronic diseases making transitions across healthcare settings. The services provided included care planning, coordination of care, phone support, home visits, liaison with medical and community services, and individual with stroke and caregiver education. In most of the studies, economic, psychosocial and functional benefits were associated with system navigation. While the services of a registered occupational therapist, who functioned as a community stroke navigator, resulted in significant improvements in the mean daily functioning subscale of the Reintegration to Normal Living Index (RNLI) among 51 patients at the end of four months, (54.1 to 59.3, p=0.02), there were no significant improvements in other outcomes (2-minute walk test, depression outcomes), or any caregiver outcomes.⁷⁶

Interprofessional Communication

Transitions between and within health care settings pose a safety and quality of care concern for individuals recovering from stroke. A consensus policy statement by the American College of Physicians in 2009 highlighted concerns of safety at transition points, particularly between inpatient and outpatient care.⁷⁷ A stroke survivor is vulnerable to many of these transition points as they progress through the acute, subacute 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 safety and quality of care. A systematic review, ⁷⁸ sought to assess the impact of co-ordinated multidisciplinary 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.⁷⁹ 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%). PCPs received notification of discharge in only 23% of cases. In a controlled study of 3,248 hospitals, Mitchell ⁸⁰ explored the association between physician/nurse communication with the individual with stroke 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. Individuals with stroke 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. ⁸¹ 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 individual with stroke 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. ⁸² 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 individuals from hospital. The final checklist included 3 types of discharge documents: the discharge summary, 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 individual 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 individual care; however, the topic has not been well researched within interdisciplinary healthcare teams. In a qualitative study of operating room personnel conducted in Ontario,⁸³ 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.