Post-Stroke Care

Care coordination following hospital discharge helps patients find their way forward to optimal recovery, health and independence.

Strategies Related to Post-Stroke Care

Support post-acute care transition planning
Prior to discharge, educate patient, family, and caregivers about transition planning
- Adult Stroke Resources
  
  UNC Department of Neurology resources for patients and caregivers from basics of stroke to NC Vocational Rehab information
- COMPASS Study Patient Handouts
  
  Disease management, insurance, and secondary prevention for patients and caregivers
Use Transitions of Care protocols
- Encourage consistency across NC
- Use a checklist to standardize care transitions
- Build on minimum standards for post-acute care: call within 2 business days of discharge, schedule follow-up visit within 7-14 days of discharge, develop individualized care plan
- Advanced Practice Providers
  
  COMPASS Study transitional care resources, assessments, and trainings
- CMS Transitional Care Management Booklet
  
  CMS resource for Medicare providers
- EHR-Integrated Data
  
  For creating individualized care plans
- Guidelines for Adult Stroke Rehabilitation and Recovery
  
  American Stroke Association
- Post-Acute Coordinators
  
  COMPASS Study transitional care resources, assessments, and trainings
Encourage care coordination
Integrate across providers including physicians, advanced practice providers, nurses, therapists (PT, OT, and ST), pharmacists, and others
- AHA Supports CHWs to Prevent and Treat CVD
  
  The American Heart Association (AHA) supports CHWs to prevent and treat CVD
- CDC CHW Resources
  
  CDC Public Health Gateway for public health professionals provides CHW resources
- CDC Community Health Worker Toolkit
  
  Resources, online courses, and best practices to help train and build capacity for CHWs
- Community Health Worker Training in North Carolina
  
  NC CHW standardized statewide trainings for certification
- CPSTF Recommends Community Health Worker Interventions to Prevent Cardiovascular Disease
  
  The Community Preventive Services Task Force (CPSTF) recommends interventions that engage community health workers to prevent CVD
- Home Health and Outpatient Rehab Providers
  
  COMPASS transitional care resources, assessments, and trainings
- NC Office on Rural Health Community Health Workers (CHW)
  
  CHW resources, training, and news about opportunities for certification
- Primary Care Providers and Pharmacists
  
  COMPASS transitional care resources, assessments, and trainings
- Rural Health Information Hub
  
  Info and tool kits to promote Patient Navigators and Community Health Workers
Integrate within EHR systems
- EHR-Integrated Data
  
  For creating individualized care plans
Develop a standard checklist
- Whom to call if/when (local number) and specific topic-based resources
- 2-1-1 resources
  
  Housing, food, healthcare, aging and disability services for all citizens of NC. Available also by phone at 2-1-1.
- Aunt Bertha Referral Platform
  
  National zip code-level resources that connect people to programs
- COMPASS Study Community Resource Directory
- NCCARE360
  
  statewide coordinated care network which electronically connects people to community resources; available in every county in NC by the end of 2020
Promote awareness of and access to post-stroke care services and/or resources
Conduct pre-discharge assessment for post-stroke care services and make referrals
- Directory of County Health Departments
  
  NC Department of Health and Human Services
- Directory of Free & Charitable Clinics
  
  NC Association of Free & Charitable Clinics
- Map of Community Health Centers
  
  NC Community Health Center Association
- Pediatric Strokes: Parent and Family Guide
  
  UNC Pediatric Stroke Resource and Brochure
- Post-Stroke Checklist
  
  Canadian Stroke Best Practices
Strengthen stroke support networks
- Regionalize the stroke support networks for long-term sustainability and geographic identity
- Connect patients to post-stroke community
- COMPASS Study Community Resource Directory
- COMPASS Study Guide on Community Engagement
- COMPASS Study Support Network
  
  For both patients and caregivers
- NC Regional Long Term Care Ombudsman List
  
  NC Division of Aging and Adult Services resource for those needing assistance while receiving rehab in long term care facility/rehab
- Post-Stroke Rehabilitation Booklet
  
  US Department of Health and Human Services
- Recovering from Stroke Tip Sheet
  
  American Occupational Therapy Association
- Right Hemisphere Brain Damage
  
  Resource for understanding impairments that result after right brain stroke
- Stroke Support Groups
  
  Located in North Carolina
- Triangle Aphasia Project
  
  Supports individuals who have aphasia and their caregivers through community building, education and group activities; online offerings available to all
- United Stroke Alliance
  
  is a non-profit organization dedicated to educating people on the prevention, awareness and recovery of stroke for survivors, caregivers and their families; online offerings available to all
Diagnose and manage post-stroke depression
- COMPASS Study Patient Handouts
  
  Disease management, insurance, and secondary prevention for patients and caregivers
- COMPASS Study Support Network
  
  For both patients and caregivers
- Depression and Stroke
  
  American Stroke Association
- Depression Self-Screening Test
  
  Mental Health America
- Mental Health Providers in NC
  
  Department of Health and Human
- Patient Health Questionnaire
  
  For depression screening
- Patient Screening for Depression
  
  Workflow in an outpatient setting
Address caregiver burnout
- COMPASS Study Patient Handouts
  
  Disease management, insurance, and secondary prevention for patients and caregivers
- COMPASS Study Support Network
  
  For both patients and caregivers
- Post-Acute Coordinators
  
  COMPASS Study transitional care resources, assessments, and trainings
Access wellness services and resources
- Address geographic or economic disparities in the determinants of stroke
- COMPASS Study Community Resource Directory
- COMPASS Study Guide on Community Engagement
- Post-Acute Coordinators
  
  COMPASS Study transitional care resources, assessments, and trainings
Identify community-based resources
- Area Agencies on Aging
  
  Regional support programs for older adults
- Community Pharmacy Enhanced Services Network (CPESN)
  
  Integrating pharmacists into the Medical Home Team
- COMPASS Study Community Resource Directory
- FaithHealth Resources
  
  Linking stroke survivors and caregivers to faith-based services
- Healthy Aging NC
  
  Falls Prevention and other programs from NC Center for Health & Wellness
- Mental Health Providers in NC
  
  Department of Health and Human
- NC DHHS Vocational Rehabilitation Services
  
  help people with disabilities achieve their goals for employment and independence
- NC MedAssist
  
  For free medications for NC citizens below 200% of the Federal Poverty Level
- Post-Acute Coordinators
  
  COMPASS Study transitional care resources, assessments, and trainings
- Primary Care Providers and Pharmacists
  
  COMPASS transitional care resources, assessments, and trainings
- Vidant Health Community Resources including Support Groups and Resource Guide
  
  Provides national, state, county and local resources for the 29-county region in eastern North Carolina that Vidant serves
Collaborate with Joint Commission, AHA Get With the Guidelines, and COMPASS to develop post-acute stroke metrics
Hospital treatment
- COMPASS Study Publications
Support patient reintegration into community
- Functional outcomes
- Back to work
- Mental state
- Resources accessed (quantity, usage)
- Secondary stroke
- Advanced Practice Providers
  
  COMPASS Study transitional care resources, assessments, and trainings
- Choosing the Right Stroke Rehab Facility
  
  American Stroke Association
- COMPASS Study Community Resource Directory
- Mental Health Providers in NC
  
  Department of Health and Human
- NC DHHS Vocational Rehabilitation Services
  
  help people with disabilities achieve their goals for employment and independence
- Post-Acute Coordinators
  
  COMPASS Study transitional care resources, assessments, and trainings
- Rehab Therapy After Stroke
  
  American Stroke Association
- Suicide Prevention Lifeline
  
  1-800-273-TALK (8255) provides free and confidential support 24/7
Provide education about stroke prevention
(Also see Stroke Prevention strategies)
- Adult Stroke Resources
  
  UNC Department of Neurology resources for patients and caregivers from basics of stroke to NC Vocational Rehab information
- COMPASS Study Support Network
  
  For both patients and caregivers

Click on each of the five categories for strategies and resources.

prevention

stroke care

post stroke care