(Adapted from Australian and New Zealand Living Clinical Guidelines for Stroke Management)
1.1. Discharge planning is essential for a smooth transition back into the community and for making efficient use of hospital resources.
1.2. Effective communication among healthcare teams, stroke survivors, families, and community providers are crucial. Key areas to focus on include setting goals, holding team and family meetings, sharing information, and planning for post-discharge care.
1.3. Stroke survivors and their families should receive personalized information in clear language at different stages of recovery. It’s important to actively involve stroke survivors and their families by providing helpful materials and opportunities for follow-up. (Crocker et al 2021)
1.4. Discharge planning should begin as soon as the stroke patient is admitted ensuring a comprehensive approach.
(Adapted from Australian and New Zealand Living Clinical Guidelines for Stroke Management)
To ensure a safe discharge process, hospital services should ensure the following steps are completed prior to discharge:
2.1. Stroke survivors and families/carers have the opportunity to identify and discuss their post discharge needs (physical, emotional, social, recreational, financial and community support) with relevant members of the multidisciplinary team.
2.2. It is recommended for the primary team to prepare transfer of care / progress documents of the patients to be discharged into the community for smoother continuation of care.
2.3. All medications, equipment and support services necessary for a safe discharge are organised.
2.4. Any necessary continuing specialist treatment required has been organised.
2.5. A documented post-discharge care plan is developed in collaboration with the stroke survivor and family and a copy provided to them. This discharge planning process may involve relevant community services, self-management strategies (i.e. information on medications and compliance advice, goals and therapy to continue at home), stroke support services, any further rehabilitation or outpatient appointments, and an appropriate contact number for any post-discharge queries.
2.6. A locally developed protocol or standardised tool may assist in implementation of a safe and
comprehensive discharge process. This tool should be aphasia and cognition friendly.