Clinical Guidelines for Acute Stroke Management - Living on the EDge

8.4 Care plans
Section 8 Discharge Planning, Transfer of Care and Integrated Community Care
A care plan is normally completed prior to discharge
and identifies appropriate management strategies to
guide care after the stroke survivor returns to the
community. Care plans are based on the needs
identified in the pre-discharge assessment, and are
useful in building self-management strategies <strong>for</strong> those
with stroke. All team members, including the person
with stroke, the family/carer, the general practitioner,
and community-based service providers are ideally
involved in developing and documenting an agreed
plan that takes into account the complex adjustments
needed, especially when changing settings or care.
A <strong>for</strong>mal family meeting or conference is often used
to develop such a plan.
Evidence <strong>for</strong> discharge planning (one component of
the total care planning process) is unclear. 456 This
suggests care plans are often one component of a
complex service delivery (e.g., early supported
discharge or inpatient integrated pathway). In many of
the trials it is difficult to determine the evidence <strong>for</strong> this
specific component.
CONSUMER
8.4 CARE PLANS GRADE LEVEL RATING
a) People with stroke, their carers, the general practitioner, and ✓ – 9.7/10
community care providers should be involved with the
interdisciplinary team in the development of a care plan.
b) Care plans should be used and outline care in the community after ✓ – 9.7/10
discharge, including the development of self-management
strategies, provision of equipment and support services, and
outpatient appointments.
8.5 Discharge planner
Effective communication regarding inpatient
management and future management plans remains
an important part of good stroke care. Discharge
planning may be coordinated by one member of the
team (e.g. inpatient care coordinator) or it may be
undertaken by someone who coordinates discharges
<strong>for</strong> multiple teams (or the whole hospital). One lower
level trial involving a comprehensive discharge
planning program <strong>for</strong> people with craniotomy or
stroke, coordinated by a discharge planner, reduced
length of stay and readmissions, but did not change
function or patient satisfaction. 457 Two relevant
systematic reviews were identified, however, neither
review provided clear conclusions.
44, 456
Any person coordinating discharge should provide the
person with stroke and their family/carer with
appropriate in<strong>for</strong>mation regarding the details of any
community services, possible waiting times, costs and
contact details prior to discharge. Good pre-discharge
care planning addresses these communication issues
and supports effective transfer of care.
CONSUMER
8.5 DISCHARGE PLANNER GRADE LEVEL RATING
a) A discharge planner may be used to coordinate a comprehensive D Level III-3 457 –
discharge program <strong>for</strong> people with acute stroke.
b) The stroke survivor’s general practitioner, other primary health
professionals and community service providers should be involved
in, and in<strong>for</strong>med about, the discharge plans and agreed
post-discharge management, as early as possible prior to discharge. ✓ – –
54