Highlights of the moderate and significant updates as well as new additions to Managing Stroke Transitions of Care module recommendations for 2015 include:

•   A focus on patient-centred care, with the patient, family members and caregivers included as active members of the stroke team, being involved in decision-making, goal setting and care planning throughout the stroke care continuum;
  
•   Recognition that stroke affects the whole family unit, and places a burden on family members; ensuring caregiver capacity, coping, and risk for depression are assessed and monitored;
  
•   The importance of educating patients and families to understand the nature and cause of stroke, the signs and symptoms, the impact and the ongoing needs of the patient who has experienced a stroke;
  
•   A call to action for all healthcare professionals for delivering education and support on an ongoing basis, regardless of patient location within the healthcare system, including providing new information at the right teachable time, reinforcing previously taught information, and assessing ongoing learning needs; these information needs evolve as the patient moves through the continuum of care and into longer term recovery;
  
•   Promotion of self-management and active participation in ongoing care, adhering to rehabilitation plans and actively engaging in recovery, and following through with decisions to take prescribed medications;
  
•   An emphasis on improving communication: between healthcare professionals and the patient, family and caregivers; and between healthcare professionals, particularly when patients are transitioning between care settings or discharged home.