Discharge Planning and Transition of Care

Discharge planning is an important component in the care process of patient management, especially for those recovering from a stroke. A structured discharge planning process identifies the type of care a patient with stroke will likely encounter after being discharged from a healthcare facility. This ensures that patients receive full support during their recovery after leaving the hospital. Continuity of care is vital to prevent adverse events and reduce unnecessary hospital readmissions. Early supported discharge (ESD) is an extension of stroke unit care in the community, wherein the patient is discharged home early, and a multidisciplinary stroke team coordinates the home-based treatment and rehabilitation efforts. Good community support and caregiver motivation, as well as patient responses, are vital for this model. There are significant barriers that contribute to ESD in low- and middle-income countries (LMICs). Transition of care (ToC) involves ensuring a smooth transition from care in the inpatient setting to the community. A comprehensive discharge plan with community-based rehabilitation efforts can ensure a smooth transition of care. However, significant financial, social, infrastructural, and educational barriers persist in the implementation of a smooth ToC in many LMICs.