Publication date: Available online 19 November 2018
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Kristine K. Miller, Susan H. Lin, Marsha Neville
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.
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