When a stroke patient is sent home from hospital, their carers become de facto health care managers. Transitional care following discharge from acute care settings can be poorly planned, fragmented and confusing for stroke patients, their carer’s and the health professionals involved. If planned continuity of care fails, it places the patient at risk for complications, medication related problems, delayed service delivery and potential readmission. This study will evaluate the transitional care planned and delivered to stroke patients discharged from an acute care facility, against recommended practices for transitional care and trial an alternate model of care that can be translated into practice and improve transitional care for stroke patients and their carers.
Evaluating transitional care - When a stoke patient goes home