Key Components of Transition

These key components of transition, taken from page 4 of the best practice document, encapsulate for me the direction I would like to see the module take and the scope of coverage:

All members of the healthcare team for stroke patients and families are responsible for taking action to ensure successful transitions and facilitate a successful return to the community following stroke.

Key components of successful transitions include:

 collaborative goal setting between the healthcare team, patients and families, where patients and family members actively participate in discussions and planning with the healthcare team and are involved in shared decision-making;

 ongoing education for patients, families and informal caregivers that reinforces key information and verifies understanding;

 patient, family and informal caregiver education needs to occur for all stroke patients, regardless of setting; this includes in the emergency department, primary care, acute inpatient care (regardless of location of patient within the hospital), rehabilitation settings, outpatient and community settings;

 skills training appropriate to needs and goals of patients to facilitate safe transitions;

 discharge planning that begins soon after stroke admission and all relevant support services, such as home assessments and access to ambulatory and community-based rehabilitation;

 assessment of family and informal caregiver capacity to provide ongoing care for the patient with stroke, as well as their individual support needs and potential burden of care;

 timely transfer of medical information between stages of care to ensure smooth transitions in care;

 identification of and linkages to community resources, long term care and home-based care;

 ongoing surveillance of physical, psychological, social and emotional recovery, coping and adaptation following discharge from inpatient acute care and rehabilitation settings.