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.

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 health.stroke@state.mn.us.

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