Supporting patients through the transition from acute care to rehabilitation or home
Background:
Canadian Stroke Best Practices outlines key points in supporting patients through transitions.  With decreasing lengths of stay in acute care settings it is important to ensure patients, families, staff and physicians receive appropriate follow up of testing, results, or treatment plans.  Both the acute stroke team and the stroke rehabilitation team work together to provide seamless transitions to patients.  
Challenges:
For patients and families changes in their environment, MRP, allied and nursing staff and the speed at which these changes occur can be a challenge.  It is important all information is transferred between care teams in order to insure appropriate management is timely.
Goals:
In order to provide appropriate medical support during the transition from acute care to rehabilitation or home, the stoke neurologist and Nurse Practitioner will follow-up with patients once they have been discharged from acute care.  Follow up includes any outstanding test results.  Insuring the patient and family have had any questions about their acute care stay answered.  Ensuring appropriate follow up has been arranged.  First phase was to implement post-acute stoke unit discharge follow-up in the rehabilitation unit.  The goal is also to implement post discharge phone call follow up with patients that have gone home.
Evaluation: 
Tracking of any tests or consults that were pending upon discharge.  Survey and discussion with patients, staff and physicians (both acute and rehab).

Supporting Patients Across Transitions Home: The S-PATH program design and implementation