Navigating the Poststroke Continuum of Care

Stroke is a significant source of death and disability worldwide. The increasing prevalence of stroke survivors forecasts substantial socioeconomic burden and a greater need for comprehensive poststroke rehabilitative services. Despite the rapidly rising burden of cerebrovascular disease, particularly in developing countries, there has been limited implementation of multidisciplinary stroke units, a proven care modality in reducing patient mortality and improving functional outcomes. Transitioning from these acute inpatient settings to in- and outpatient rehabilitation or long-term care environments has consistently been identified as an obstacle to quality stroke rehabilitation. To address the barriers preventing the seamless delivery of poststroke care, an evaluation of patient-caregiver perspectives, treatment challenges, and system-wide shortcomings is presented. The fragmentation of the current poststroke chain of care could benefit from the introduction of case managers or "navigators," discharge planning, electronic medical records, and evidence-based neurorehabilitation guidelines. By aiding in successful care transitions, these proposed efforts could advance post-acute stroke patients along the care continuum to achieve their rehabilitative goals.