presented by Barbara Lutz & Michelle Camicia
Transitioning home and adapting to life after stroke is often difficult for stroke survivors and their family caregivers. Successful recovery and community reintegration is dependent on stroke survivors and their family members being able to adapt to the post-stroke changes in their lives. They often do not have working knowledge of community- or web-based resources that may be available to help them adjust to new limitations and changes in roles and responsibilities. Members of the interprofessional team can facilitate post-discharge adaptation by anticipating the needs of the stroke survivor and family members and linking them to the most appropriate resources. This course focuses on describing the post-discharge needs of stroke survivors and their family caregivers, assessing post-discharge needs, and identifying resources that can facilitate recovery and successful community reintegration post-stroke. Examples of community- and web-based resources are provided.
Dr. Barbara Lutz is the McNeill Distinguished Professor at the University of North Carolina-Wilmington School of Nursing. Her 30+ year career as a rehabilitation and public health nurse spans practice, research, education, and service. Her research focuses on understanding the needs and experiences of patients with stroke and other chronic illnesses and their family caregivers as they move through the continuum of care, from acute care to home. The goal of her work is to engage patients and their family caregivers in developing person and family-centered, community-based interventions for people with stroke and other chronic illnesses. She is a Co-Investigator on a PCORI-funded research study to test a person-centered, community-based Emergency Department (ED) to Home transitional care intervention developed in partnership with a research team that includes former patients, family caregivers, social workers, ED physicians, staff of two local Area Agencies on Aging, and health services researchers. Dr. Lutz is a Fellow in the American Academy of Nursing, American Heart Association (AHA), and National Academies of Practice. She is a board member of the Association of Rehabilitation Nurses and is a co-author on a position paper on the transitional care needs for patients needing rehabilitation services and on AHA scientific statements on palliative care in stroke, risk adjustment for stroke, and best evidence on stroke caregiver interventions. She has also served as a member of the ANA Care Coordination Quality Measures Steering Committee and as a rehabilitation expert on the Joint Commission Technical Advisory Panel for Comprehensive Stroke Center Certification.
Michelle Camicia, PhD, MSN, CRRN, CCM, NEA-BC, FAHA, is the Director of Operations for Kaiser Foundation Rehabilitation Center at the Vallejo Medical Center. She is responsible for day-to-day operations of the Center as well as outreach, quality, and regulatory oversight. Michelle is a past president of the Association of Rehabilitation Nurses. She has participated in numerous national and international advisory panels and committees related to professional nursing practice, rehabilitation, and health care reform and has published 13 peer-reviewed publications. Michelle currently serves on the National Institutes for Health National Advisory Board for Medical Rehabilitation Research, the National Quality Forum Neurology Standing Committee, and the Editorial Board of Rehabilitation Nursing and is chair-elect of the American Heart/Stroke Association International Stroke Conference State-of-the-Science Symposium. Michelle recently finished her doctorate in nursing and health care leadership program at The Betty Irene Moore School of Nursing at the University of California, Davis. She is studying the predictive validity of the Preparedness Assessment for the Transition Home after Stroke (PATH-s), a novel instrument she developed with a colleague to assess stroke caregivers' commitment and capacity for the caregiving role.
Family-centered care requires that the health care team identify and address the needs and concerns of patients and their families. In this chapter, the most common post-discharge needs of stroke survivors and their caregivers are discussed to help nurses, therapists, and other health care providers recognize these needs in order to better tailor care plans for post-discharge support and follow-up.
A systematic and comprehensive assessment can help identify post-discharge needs and establish priorities for referrals and follow-up care. In this chapter, the elements of a comprehensive assessment are discussed and strategies for working with stroke survivors and family members to prioritize follow-up care are recommended.
Stroke survivors and their family members are often unaware of available community and web-based resources that can provide support and facilitate community reintegration post-stroke. In this chapter, community- and web-based resources addressing the post-discharge needs of stroke survivors and their family members will be described. Novel programs and resources that nurses, therapists, and other health care providers might consider implementing in post-discharge stroke care will be discussed.