Transitions of Care for Stroke Patients - Minnesota Department of Health

Transitions of Care for Stroke Patients

At the Minnesota Department of Health, we are putting strategies in place to improve care to stroke patients who are going home from the hospital. We work with health systems, hospitals, clinics and other partners to support the smooth transition of a patient’s care between providers to:

  • Improve patient and caregiver education
  • Help stroke survivors and their families navigate the health system
  • Find resources to meet their needs

Transitions of care

Transitioning patients between care settings requires coordination between health professionals. This coordination makes sure that a patient’s health and personal needs are met, and that the right person is delivering the right care and services at the right time.

Creating a smooth transition for stroke patients from hospital discharge to their homes and communities requires building connections between hospitals, post-acute facilities, home care agencies, clinics, and community-based organizations.

Reducing readmissions through improved transitions of care

In the past 10 years, Minnesota has made significant progress improving emergency treatment and inpatient care for acute stroke patients. However, the transition back home for these patients after hospital discharge remains difficult.

Many stroke patients experience health complications, are readmitted within 30 days, and often have a difficult time transitioning back to their lives. Studies show that interventions like close coordination of care, along with early follow-up care after hospital discharge, have lowered readmission rates.

Transitions of care strategies

The Minnesota Department of Health Stroke Program provides support for improving transitions of care.

Strategies include:

  • Work with three hospitals to put in place emerging practices that support the smooth transition of a patient’s care between providers.

    Two hospitals are working with their affiliated primary care clinics to provide care coordination and follow-up for stroke patients discharged from the hospital to home. One hospital is working with their affiliated community paramedic program to offer home visits for stroke patients after they leave the hospital.
  • Facilitate a learning project that supports stroke survivors who began treatment in a community hospital and were transferred to a larger hospital with specialists, and then came back home to be cared for by their local doctors. We will share the best practice models with hospitals and clinics across Minnesota.
  • Provide support for hospitals and clinics to collect quality of care data after discharge. This data will allow hospitals or clinics to identify areas for improvement.

If you would like to learn more about the transitions of care work or would like to learn how your hospital or health system can get involved, contact

Resources: Find all of the documents, tools, guidance documents, and resources produced by the Stroke Program for our partners.

Updated Tuesday, 12-Nov-2019 11:15:45 CST