Quality statement 7 Transition from hospital – care Before a patient with stroke leaves the hospital, they are involved in the development of an individualised care plan that describes the ongoing care that the patient will require after they leave the hospital. The plan includes rehabilitation goals, lifestyle modifications and medicines needed to manage risk factors, any equipment they need, follow-up appointments, and contact details for ongoing support services available in the community. This plan is provided to the patient before they leave hospital, and to their general practitioner or ongoing clinical provider within 48 hours of discharge. Indicator 7a: Written care plan Collection and usage attributes Computation: (Numerator ÷ denominator) x 100 Definitional attributes Numerator: Total number of patients with a Name: Proportion of patients with a final final diagnosis of stroke with diagnosis of stroke, with evidence evidence that a documented plan that a documented plan for their for their ongoing care in the ongoing care in the community was community was developed with developed with and provided to the and provided to the patient and/or patient and/or their carer prior their carer prior to discharge into to discharge.1 the community.2 Rationale: A range of interventions have been Numerator shown to reduce the risk of another criteria: Inclusions stroke and are outlined in the Patients diagnosed with stroke Clinical Guidelines for Stroke (I61.x, I62.9, I63.x and 164).a Management. A written care plan should address all relevant lifestyle Separation mode =‘9’ modifications. The plan aims to (discharge to usual residence encourage self-management or own accommodation).b strategies to assist the patient in Exclusions maximising their recovery Nil. from stroke. a ICD-10-AM (9th edition). b METeOR identifier: 270094. Includes discharge to usual residence, own accommodation or welfare institution (includes prisons, hostels and group homes providing primarily welfare services).
Quality statement 7 – Transition from hospital care Before a patient with stroke leaves the hospital, they are involved in the development of an individualised care plan that describes the ongoing care that the patient will require after they leave the hospital. The plan includes rehabilitation goals, lifestyle modifications and medicines needed to manage risk factors, any equipment they need, follow-up appointments, and contact details for ongoing support services available in the community. This plan is provided to the patient before they leave hospital, and to their general practitioner or ongoing clinical provider within 48 hours of discharge. Indicator 7a: Written care plan Definitional attributes Name: Proportion of patients with a final diagnosis of stroke, with evidence that a documented plan for their ongoing care in the community was developed with and provided to the patient and/or their carer prior to discharge.1 Rationale: A range of interventions have been shown to reduce the risk of another stroke and are outlined in the Clinical Guidelines for Stroke Management. A written care plan should address all relevant lifestyle modifications. The plan aims to encourage self-management strategies to assist the patient in maximising their recovery from stroke. Collection and usage attributes Computation: (Numerator ÷ denominator) x 100 Numerator: Total number of patients with a final diagnosis of stroke with evidence that a documented plan for their ongoing care in the community was developed with and provided to the patient and/or their carer prior to discharge into the community.2 Numerator criteria: Inclusions Patients diagnosed with stroke (I61.x, I62.9, I63.x and 164).a Separation mode =‘9’ (discharge to usual residence or own accommodation).b Exclusions Nil. a ICD-10-AM (9th edition). b METeOR identifier: 270094. Includes discharge to usual residence, own accommodation or welfare institution (includes prisons, hostels and group homes providing primarily welfare services).