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
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Support post-acute care transition planning
Prior to discharge, educate patient, family, and caregivers about transition planning
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Adult Stroke Resources
UNC Department of Neurology resources for patients and caregivers from basics of stroke to NC Vocational Rehab information
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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
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Advanced Practice Providers
COMPASS Study transitional care resources, assessments, and trainings
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CMS Transitional Care Management Booklet
CMS resource for Medicare providers
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EHR-Integrated Data
For creating individualized care plans
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Guidelines for Adult Stroke Rehabilitation and Recovery
American Stroke Association
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Post-Acute Coordinators
COMPASS Study transitional care resources, assessments, and trainings
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Encourage care coordination
Integrate across providers including physicians, advanced practice providers, nurses, therapists (PT, OT, and ST), pharmacists, and others
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AHA Supports CHWs to Prevent and Treat CVD
The American Heart Association (AHA) supports CHWs to prevent and treat CVD
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CDC Resources for CHWs
Community Health Workers resources
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Community Health Worker Training in North Carolina
NC CHW standardized statewide trainings for certification
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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
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Home Health and Outpatient Rehab Providers
COMPASS transitional care resources, assessments, and trainings
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NC Community Health Worker Association
Sets standards and provides training for certification.
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NC Office on Rural Health Community Health Workers (CHW)
CHW resources, training, and news about opportunities for certification
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Primary Care Providers and Pharmacists
COMPASS transitional care resources, assessments, and trainings
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Rural Health Information Hub
Info and tool kits to promote Patient Navigators and Community Health Workers
Integrate within EHR systems
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EHR-Integrated Data
For creating individualized care plans
Develop a standard checklist
- Whom to call if/when (local number) and specific topic-based resources
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2-1-1 resources
Housing, food, healthcare, aging and disability services for all citizens of NC. Available also by phone at 2-1-1.
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Aunt Bertha Referral Platform
National zip code-level resources that connect people to programs
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NCCARE360
statewide coordinated care network which electronically connects people to community resources; available in every county in NC by the end of 2020
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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
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Directory of County Health Departments
NC Department of Health and Human Services
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Directory of Free & Charitable Clinics
NC Association of Free & Charitable Clinics
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Map of Community Health Centers
NC Community Health Center Association
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Pediatric Strokes: Parent and Family Guide
UNC Pediatric Stroke Resource and Brochure
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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
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A list of Stroke Support Groups
Located in North Carolina
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COMPASS Study Support Network
For both patients and caregivers
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NC Regional Long-Term Care Ombudsman Program
NC Division of Aging and Adult Services resource for those needing assistance while receiving rehab in long-term care facility/rehab
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Post-Stroke Rehabilitation Booklet
US Department of Health and Human Services
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Recovering from Stroke Tip Sheet
American Occupational Therapy Association
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Right Hemisphere Brain Damage
Resource for understanding impairments that result after right brain stroke
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The Aphasia Project
Supports individuals who have aphasia and their caregivers through community building, education and group activities; online offerings available to all
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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
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COMPASS Study Patient Handouts
Disease management, insurance, and secondary prevention for patients and caregivers
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COMPASS Study Support Network
For both patients and caregivers
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Depression and Stroke
American Stroke Association
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Depression Self-Screening Test
Mental Health America
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Mental Health Providers in NC
Department of Health and Human
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Patient Health Questionnaire
For depression screening
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Patient Screening for Depression
Workflow in an outpatient setting
Address caregiver burnout
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COMPASS Study Patient Handouts
Disease management, insurance, and secondary prevention for patients and caregivers
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COMPASS Study Support Network
For both patients and caregivers
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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
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Post-Acute Coordinators
COMPASS Study transitional care resources, assessments, and trainings
Identify community-based resources
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Area Agencies on Aging
Regional support programs for older adults
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Community Pharmacy Enhanced Services Network (CPESN)
Integrating pharmacists into the Medical Home Team
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FaithHealth Resources
Linking stroke survivors and caregivers to faith-based services
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Healthy Aging NC
Falls Prevention and other programs from NC Center for Health & Wellness
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Mental Health Providers in NC
Department of Health and Human
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NC DHHS Vocational Rehabilitation Services
help people with disabilities achieve their goals for employment and independence
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NC MedAssist
For free medications for NC citizens below 200% of the Federal Poverty Level
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Post-Acute Coordinators
COMPASS Study transitional care resources, assessments, and trainings
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Primary Care Providers and Pharmacists
COMPASS transitional care resources, assessments, and trainings
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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
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Collaborate with Joint Commission, AHA Get With the Guidelines, and COMPASS to develop post-acute stroke metrics
Hospital treatment
Support patient reintegration into community
- Functional outcomes
- Back to work
- Mental state
- Resources accessed (quantity, usage)
- Secondary stroke
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Advanced Practice Providers
COMPASS Study transitional care resources, assessments, and trainings
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Choosing the Right Stroke Rehab Facility
American Stroke Association
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Mental Health Providers in NC
Department of Health and Human
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NC DHHS Vocational Rehabilitation Services
help people with disabilities achieve their goals for employment and independence
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Post-Acute Coordinators
COMPASS Study transitional care resources, assessments, and trainings
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Rehab Therapy After Stroke
American Stroke Association
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Suicide Prevention Lifeline
1-800-273-TALK (8255) provides free and confidential support 24/7
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Provide education about stroke prevention
(Also see Stroke Prevention strategies)
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Adult Stroke Resources
UNC Department of Neurology resources for patients and caregivers from basics of stroke to NC Vocational Rehab information
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COMPASS Study Support Network
For both patients and caregivers
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Click on each of the five categories for strategies and resources.
