Authors: Ashwag Osman

Abstract

Acute stroke care has increased survival, and recovery following the acute admission requires coordinated rehabilitation and follow-up. Medical stability refers to the management of an acute physiological threat and the lack of an urgent requirement for acute intervention but not to a return of function nor to the conclusion of rehabilitation needs. This Opinion refers to a clinical example that has been anonymized to prompt discussion on transitions for people with stroke, including migrant workers and those with financial or administrative limitations. This Opinion does not assume a failure of care or lack of rehabilitation simply because there was a transfer/repatriation. The question is whether an appropriate and feasible rehabilitation pathway exists and is shared across settings. Early multidisciplinary assessment, functional needs to be documented, medication reconciliation, direct communication with receiving services, if possible, accessible patient and caregiver education and social and financial barriers to be assessed are recommended. These actions should be informed by a commitment to safe, person-centered transitions, but not as a substitute for recovery.

Keywords: Stroke, rehabilitation, continuity of care, health equity, migrant health, discharge planning.