From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke
Archives of Physical Medicine and Rehabilitation
Miller, K. K., Lin, S. H., et al. (2019).
Archives of Physical Medicine and Rehabilitation, 100(6), 1162-1175.
This guideline provides recommendations for supporting and standardizing a patient's transition to home post-stroke. The target audience of this guideline is clinical providers.
American Congress of Rehabilitation Medicine Stroke Group's Movement Interventions Task Force
For patients who have experienced a stroke, the home transition process should include a clear communication process that involves the following:
<ol>
<li>Identify clinical care providers within each level and system of patient care who will send and receive patient communications.</li>
<li>Include a case manager and/or transition specialist who will be one of the communication receiving providers.</li>
<li>Consistently use a checklist, such as the "Patient-Centered Checklist for Discharge to Community (PCC-DC)," to ensure all appropriate information is shared between the patient, transition specialist, and clinical care providers.</li>
</ol>
For patients who have experienced a stroke, appropriate standardized outcome measures should be consistently utilized between levels of care and healthcare systems to support ease of post-stroke transitions for patients and their caregivers.
