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Stroke Smart Magazine

May/June 2008

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Use a Discharge Planner: Ease Into a New Level of Care

By Jonathan Bitz

A stroke doesn't just change the life of the survivor; it changes the life of family members as well. After a stroke, the family helps direct the survivor’s next steps. This can be overwhelming for many people. A discharge planner can focus a new caregiver on the important questions and help the family make decisions.

Discharge planners can be nurses, case managers or social workers. The role of the discharge planner is to help patients make a smooth transition. For stroke survivors, the transition is usually from the hospital to a care facility or the home. The discharge planner works with the stroke survivor, family and health care team to assess needs and to set goals that will meet those needs.

Joanne Fritz Kraus, a senior clinical social worker at Johns Hopkins Bayview Medical Center, says not all discharge planners approach the process the same way, but they do tend to cover the same areas.

Here is a sample of what a discharge plan may address:

  • What does the patient need in terms of rehab physical, occupational and/or speech therapy?
  • What kind of support does the patient have? Is there a spouse? Will family members be involved?
  • Are there any barriers in the patient’s house?
  • What roles did the patient have prior to the stroke? Homemaker? Business professional?
    Parent? Child?
  • What health care provider will monitor the stroke survivor’s health and medical needs?

According to Kraus, a partnership is the ideal relationship between a discharge planner and the family. The family represents the stroke survivor’s wishes and needs and is an integral part of the decision process. After a stroke, spouses, parents, children and siblings can turn into caregivers. While this can be intimidating and stressful, it is a learning experience. New caregivers need to be patient and gentle with themselves. And by working with discharge planners, unnecessary stress can be avoided or reduced.

10 Tips for a New Caregiver:

1. Know the care requirements of your patient.

2. Ask questions and take lots of notes.

3. Keep all records in a safe, easy-to-find place.

4. Assess your abilities as a caregiver.

5. Know what physical, financial and emotional resources you have.

6. Develop relationships with professional caregivers near your survivor.

7. Develop an ability to deal with stressors as a caregiver.

8. Know your expectations for a rehabilitation facility.

9. Take care of yourself. There may not be anybody else who can fill your shoes. Your
stroke survivor is depending on you.

10. Know that caregiving is learned. Your knowledge and skills will grow. Be patient.



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National Stroke Association’s mission is to reduce the incidence and impact of stroke by developing compelling education and programs focused on prevention, treatment, rehabilitation and support for all impacted by stroke.

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