E12: Seamless transfer of care

A workable, clear discharge plan that has fully involved the individual (and their family where appropriate) is developed by health and social care services, together with other services such as transport and housing. (Key: e = element | k = knowledge | s = skill)

Knowledge and understanding of…

The assessment and management of problems: psychological and emotional; social and relationship; cognitive and communication; physiological, physical and functional; neurological, visual and sensory impairments and pain; medical; and how to involve users and carers
Advocates for stroke patients when there is a legal duty to instruct an IMCA, taking account of religious and cultural aspirations
The implications of stroke for lifestyle, driving, work and family
Methods to facilitate communication with those affected by stroke
Support services, organisations and resources available (e.g. health, social, voluntary, independent sector; packages of care, finance and personal budgets, self management, respite care, equipment, adaptations, rehabilitation, psychological, educational, employment, housing, transport) including exit strategies
The principles of good planning for transition between services or cessation of services and for transfer of care to the community, including the education of those affected by stroke
All agencies that are potentially involved along the whole of the Stroke Pathway
The principles of multi-agency working

Skills and ability to...

Take and interpret thorough history, including information from carers, relatives and other agencies where possible, and assess mental capacity
Determine, plan and initiate appropriate assessments/investigations and interventions/treatments; provide information, relevant to individual needs and aspirations (personalise information)
Assess, discuss and review with those affected by stroke: goal-setting, outcomes and exit strategies
Monitor progress and agree or change a maintenance or management plan
Identify need and when to refer for more specialist or differing treatments where necessary
Identify local services and resources (e.g. health, social, voluntary, independent sector; equipment and adaptations, rehabilitation, psychological, educational, employment, housing, transport) to facilitate participation and inclusion: check availability and waiting times; inform individual about services, identify how to access, or re-access, them and agree referral
Liaise with and work across agencies
Identify and utilise resources available locally and nationally to support those affected by stroke
Reflect on processes and pathways of care including mechanisms for review and exit strategies
Reflect on methods and effectiveness of information sharing