Quality Improvement and Implementation Science
This symposium reviews current evidence about transition planning in stroke rehabilitation focusing on the transition home and into the community within the framework of the Transitions of Care model. We will describe gaps in transition care, discuss barriers and facilitators for successful transitions, discuss and evaluate relevant assessments/tools, and provide recommendations to improve care coordination for persons with stroke from hospital to home and community. The integral role of the caregiver and accessing resources in the community will be emphasized. Attendees' perspectives will be sought throughout since organizations and communities may differ in their transition process and resources.