From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke

Abstract

Based on a review of the evidence, members of the American Congress of Rehabilitation Medicine Stroke Group's Movement Interventions Task Force offer these five recommendations to help improve transitions of care for patients and their caregivers: (1) improving communication processes, (2) utilizing transition specialists, (3) implementing a patient-centered discharge checklist, (4) utilizing standardized outcome measures, and (5) establishing partnerships with community wellness programs. Due to changes in healthcare policy, there are incentives to improve transitions during stroke rehabilitation. Although transition management programs often include multidisciplinary teams, medication management, caregiver education, and follow-up care management, there is a lack of a comprehensive and standardized approach to implement transition management protocols during post-stroke rehabilitation. This article uses the Transitions of Care (TOC) model to conceptualize how to facilitate a comprehensive patient-centered hand-off at discharge to maximize patient functioning and health. Specifically, this article reviews current guidelines and provides an evidence summary of several commonly cited approaches (early supported discharge, planned pre-discharge home visits, discharge checklists) to manage TOC, followed by a description of documented barriers to effective transitions. Patient-centered and standardized transition management may improve community integration, activities of daily living performance, and quality of life for stroke survivors while also decreasing hospital readmission rates during the transition from hospital to home to community.

Evaluating the implementation of an early supported discharge (ESD) program for stroke survivors: A mixed methods longitudinal case study

“…These areas of agreement and difference may tentatively indicate which aspects of the ESD model are core (and transferable as essential elements), and which are peripheral (and therefore adaptable to local conditions) [17]. Given the variability in ESD models of care being implemented globally [4,15], further research to describe its core and peripheral characteristics is important to guide its effective use.…”

“…ESD models of care share common features and components, including multidisciplinary team members, a workforce with specialist stroke care knowledge and the provision of services in the community [14,15]. However, ESD is has been implemented variably around the world, particularly in regards to recommended full time staff loadings and intensive treatment duration.…”

Clinical outcomes for moderate and severe stroke survivors receiving early supported discharge: A quasi-experimental cohort study

“…Although there can be variability in ESD protocols (for example team composition, service locations and the provision of additional supports such as transport), all models share some key features and components. In addition to the consensus study already referred to, the distinguishing characteristics of ESD have also been reported in a further Delphi study from the United Kingdom (Fisher et al, 2013), and a recent position paper (Miller et al, 2019). As shown in Table 1, the ESD model utilised in this study reflected many of the key features and components identified in these consensus documents.…”

Achieving universal health coverage for people with stroke in South Africa: protocol for a scoping review

“…17 Internationally, delivering effective stroke care has changed over the years as an understanding of stroke has increased, moving from individual care to a more comprehensive health system approach. 18 The majority of people with stroke in SA may have no or limited access to stroke care and rehabilitation. 3 19 Stroke rehabilitation is limited in the first instance by insufficient rehabilitation facilities in the public sector, as well as inadequate intensity of inpatient rehabilitation, and lack of outpatient or community-based rehabilitation.…”

“… 17 Internationally, delivering effective stroke care has changed over the years as an understanding of stroke has increased, moving from individual care to a more comprehensive health system approach. 18 …”