Article: Sharon - Best Practice Recommendation 6.1 New for 2010

Supporting Patients, Families and Caregivers Through Transitions 

Patients, families, and caregivers should be prepared for their transitions between care environments by being provided with information, education, training, emotional support, and community services specific to the transition they are undergoing [Evidence Level C].

1. Patients, families and caregivers should be assessed to determine their needs and readiness for information and education, training, psychosocial support, and health and social services [Evidence Level B]. Refer to recommendation 6.2 for additional information.
2. Patients, families and caregivers should be prepared with appropriate and realistic expectations regarding role changes, and the availability of services and resources within changing care environments [Evidence Level C].
3. Support should include:
1. written discharge instructions from care providers that identify action plans, follow-up care, and goals, provided to the patient, family, and primary care giver [Evidence Level C].  Refer to recommendation 6.3 for additional information.
2. access to a contact person in the hospital or community (designated case manager or system navigator) for post-discharge queries [Evidence Level C].
3. access to and advice from health and social service organizations (e.g., through single points of access to all organizations) [Evidence Level C].
4. referrals to community agencies such as stroke survivor groups, peer survivor visiting programs, and other services and agencies [Evidence Level C].

Best Practice Recommendation 6.2 Patient and Family Education

Stroke survivor, family and caregiver education is an integral part of stroke care that must be addressed at all stages across the continuum and at all transition points of stroke care for both adult and pediatric patients [Evidence Level A]. Patient and family education should include information sharing, teaching patients self-management skills, and training of caregivers.

1. Educational content should be specific to the phase of care or recovery and appropriate to the readiness and needs of the stroke survivor, family, and caregiver [Evidence Level B]. 492,501 The scope of the educational content should cover all aspects of stroke care and recovery [Evidence Level A].
1. General education topics should include treatment goals within each environment; community services; information about community resources that should be broadly encompassing (e.g., the broad range of therapy and treatment resources available, counseling and support groups, home renovation resources, financial/tax consultants); on-going practical information and how to seek help if problems develop [Evidence Level C]; information about the availability and potential benefits of local stroke groups [Evidence Level C].
2. Education should be interactive, up to date, ongoing, and provided in a variety of languages and formats (e.g., written, oral, group counseling approach), and ensure communicative accessibility for stroke survivors [Evidence Level B]. Specific team members should be designated to provide and document education [Evidence Level C].
3. Patient education should promote self-efficacy through mastering self-management skills, including action planning, modeling behaviors and problem-solving strategies, reinterpreting symptoms, and social persuasion through group support and guidance for individual efforts [Evidence Level B].
1. Key topics in self-management training should include exercise, symptom management techniques, risk factor management, secondary stroke prevention, nutrition, fatigue and sleep management, use of medications, managing emotions of fear, anger and depression, cognitive and memory changes, training in communication with health professionals and others, and health-related problem-solving and decision making. [Evidence Level B]
4. Family and caregiver education should include training in personal care techniques, communication strategies, physical handling techniques [Evidence Level B], other daily living activity goals and preferences, how to access community services and resources, problem-solving techniques, health system navigation, and self-management [Evidence Level C].