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 the physiological, neurological, and psychological effects of stroke to identify care and ongoing rehabilitation needs
the implications of stroke for lifestyle; driving; occupation, including voluntary work or education; and social participation
the full range of local and national resources and services available for those affected by stroke - particularly those relating to transfer, short and long-term needs assessment, packages of care, continued rehabilitation and psychological care, finance and personal budgets, and respite care - including: health, social, voluntary, and independent; how to facilitate access and length of referral time
the principles of good discharge planning for transition between services, 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...

determine, plan, and initiate appropriate assessments, including risk assessments, to determine care and support needs on discharge, and to ensure risk is minimised
assess, discuss, and review goal-setting, outcomes, and a discharge plan with those affected by stroke
Identify need and when to refer for more specialist or differing treatments where necessary
identify the full range of local and national resources and services available to overcome barriers and facilitate effective and efficient discharge for those affected by stroke; assess their relevance and suitability for the patient, carer, and family; liaise with services, working across agencies and sharing information where appropriate; communicate referral arrangements, availability and waiting times
reflect on processes and pathways of care including mechanisms for review and discharge planning
reflect on methods and effectiveness of information sharing within and between agencies involved in transfer of care and discharge planning