Preventing Rehabilitation Readmissions for Individuals with Stroke

Current post-acute care transitions are frequently fragmented, disorganized and can be confusing for patients and families. Through a coordinated and systematic approach to care transitions, readmissions to acute care may be reduced. Patients with stroke provide an excellent model for care transitions due to the complicated nature of the diagnoses, the prevalence of complications that occur and the potential to enter the healthcare system at any point along the continuum. Yet little evidence exists with respect to preventing stroke rehabilitation patients from being re-hospitalized to acute care. purpose of this capstone project was to implement and evaluate a checklist targeted to improve the transition of care in stroke patients discharged home from inpatient rehabilitation. The findings of the project suggest the checklist was effective in reducing readmissions for the stroke rehabilitation population discharged home. Further evaluation and validation is indicated by using the checklist with other rehabilitation diagnoses as well as within other rehabilitation units and facilities.