Patients and their carers should be involved in planning their care and safe discharge from hospital. This should identify an initial overview of the patient’s likely needs upon discharge, and include a fuller assessment of the issues that will impact on the patient’s independence. The assessment should result in an individual care plan which identifies proposed services, the responsibilities of various professionals for providing those services and the aims and potential outcomes of rehabilitation.

There should be an assigned stroke care co-ordinator who will be responsible for:

• Co-ordinating assessment and individual care plans and ensuring arrangements for support and secondary prevention measures are in place prior to discharge
• Ensuring an efficient flow of relevant information to community-based professionals
• Ensuring a smooth transfer between care settings
• Ensuring that the need for home adaptations, repairs and improvements are identified, and work is completed pre-discharge¹
• Ensuring family members are aware of ongoing care needs post discharge and are provided with relevant support, education and information
• Ensuring ongoing referrals are made to specialist community services and Social Services if required