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 5 recommendations
to help improve transitions of care for patients and their caregivers: (1) improving
communication processes; (2) using transition specialists; (3) implementing a patient-centered
discharge checklist; (4) using standardized outcome measures; and (5) establishing
partnerships with community wellness programs.
Because of changes in health care 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 poststroke 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 predischarge
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.
Keywords
List of abbreviations:
ADL (activities of daily living), ESD (Early Supported Discharge), OT (occupational therapy), PCC-DC (Patient-Centered Checklist for Discharge to Community), PCP (primary care physician), PHV (predischarge home visit), TOC (Transitions of Care)To read this article in full you will need to make a payment
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Article info
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Published online: November 19, 2018
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© 2018 by the American Congress of Rehabilitation Medicine
