How Hospital to Home Care Can Improve Stroke Recovery

By July 24, 2017Discharge Planning

Every year, more than 795,000 people in the United States suffer a stroke1. Each year stroke kills more than 130,000 Americans – one out of every 20 deaths. Stroke is a silent killer and strikes without warning, leaving people with disabilities that can range from mild motor skill impairment to paralysis.

In the first few days after stroke, survivors are in the hospital. Depending upon the effects of the stroke, some are discharged home while others are discharged to rehabilitation centers. Eventually all survivors must go home and the transition between hospital or rehab and home is critical to the survivor’s ability to recover from the stroke. The stronger the transition team, the better chance the survivor has to acclimate to activities of daily living.

A case in point is Wayne Kopacz who suffered a severe hemorrhagic2 stroke with no warning signs. He spent five hours undergoing brain surgery in a Pennsylvania hospital and was in intensive care for one month before being sent to a rehabilitation center. Even though the support there was strong and the staff was positive and upbeat, Wayne began to get depressed and needed to go home. He wanted to be near his family and in familiar surroundings to continue his recovery.

Fortunately, the rehabilitation center where Wayne was staying had a strong in-home care program. When he has discharged a team of rehab specialists visited him at home to continue his physical, occupational and speech therapy. He continued to make progress because he had the reassurance of being home and the skill of rehab specialists. This type of transition is considered best practices.

The American Heart Association3 says that all excellent transitions from hospital or rehab to home are based on four pillars. They are:

1. Self-care management: This involves great teaching in the hospital or rehab center so that patients and caregivers know what to do and when to call for emergency response. Each patient needs to fully understand what he or she needs to do for self-care and why it is important. Each patient needs to understand the full impact of the stroke and what recovery will entail.

2. Medication adherence: A good transition plan ensures that the patient and caregiver know when medication should be taken and the proper dose. The pharmacist should be brought in early in the process to monitor medications and watch for any potentially adverse interactions between medications.

3. Early follow up and support:A good transition plan lays the groundwork for staff at the hospital or rehab center to make follow-up calls to the survivor and caregiver. The staff can answer questions during the call and offer support. Part of a supportive transition plan is making sure that the survivor goes home with a detailed care plan that is easily understood and followed. The plan includes referrals to outpatient support like physical and speech therapy.

4. Communication and transfer of information: A successful transition plan will include hospital or rehab staff who knows how to communicate fully and in detail with the survivor and caregiver. Information should be given on printed sheets that can be taken home and referred to frequently. The survivor and caregiver should receive a discharge checklist that includes items such as a medication list, knowing when to call 911 or primary care physician, follow up appointments and comprehensive education about stroke and stroke recovery.

If you are seeking stroke care after a hospital discharge, insist that your loved one receive a robust transition plan that provides for continuing care and gives you all the information you need. It will support you through the tenuous first days after stroke. Information is power as you enter a lifetime of stroke recovery.

Learn more about LivHOME’s hospital-to-home-care program.


1: Stroke Facts
2: Hosptial Enviroment to Home
3: Transitional Care Makes Major Difference for Stroke Survivor

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