Abstract
Introduction: Nebraska Mission: Lifeline Stroke is a 4-year initiative to increase guideline-based treatment of acute stroke across the continuum of care. Guidelines advise post-stroke assessment by a multi-disciplinary team to guide discharge process and select ideal rehab setting.
Purpose: To develop resources to facilitate the transition of Nebraskans with stroke to the most appropriate level of post-acute care.
Methods: Healthcare Providers (HCPs) from various settings completed two surveys: hospital stroke rehab referral strategies and practices (N=23), and individual experiences related to stroke rehab (N=260). In addition, a literature review was conducted to find published guidelines and research on clinical decision making. Lastly, a focus group consisting of social worker/case managers was held to provide input on resources developed.
Results: Hospitals (N=23) believe higher numbers of stroke patients should be referred to IRFs (42%) and stated that patients' "health status" (91%), "opinions from hospital team members" (87%), and "opinions from patient, family, or caregivers" (78%) are most relevant in the decision process. Factors that impact referral process include: HCPs may not be familiar with all options for post-acute rehab care (17%) and patient or family/caregivers are not educated about options (30%). Most (57%) of HCPs surveyed and all focus group participants indicated discharge referral process could be improved with a standardized decision-making tool. Based on this input, two discharge planning guides were developed. The first assists HCPs in determining appropriate level of post-acute stroke care by comparing various types and settings in an easy-to-read format. The second is patient/caregiver focused and includes information to assist in decision-making process and a table comparing rehab settings. These guides have been disseminated through conference presentations, direct mailings, and web-based resources.
Conclusions: Discharge tools with clear descriptions of options are necessary to assist HCPs and patients/caregivers in matching appropriate care with patient's rehab needs. These care choices are key to patients achieving their highest level of independence.