Improving Collaborative Discharge Care Planning for Stroke Patients

St George Hospital developed an Allied Health Discharge Care Plan, established an allied health care coordinator role and implemented new administration processes, to support the transition of stroke patients out of hospital and into the community.


To increase the number of stroke rehabilitation patients at St George Hospital who are discharged with an Allied Health Discharge Care Plan, to 84 per cent by February 2018.


  • Helps patients transition out of hospital and into the community.
  • Improves the awareness of discharge care plans among patients and carers.
  • Helps patients and carers understand who to contact if issues arise after they are discharged.
  • Helps patients and carers understand what follow-up care and support services are available.
  • Ensures information about support and equipment needed for mobility, self-care and feeding is documented.
  • Provides all discharge and follow-up care information in the one document.
  • Provides a standardised template that is faster and easier for staff to complete.
  • Streamlines auditing processes of stroke rehabilitation compliance.


The Stroke Foundation developed the Clinical Guidelines for Stroke Management 2017 to provide a series of evidence-based recommendations for the management of stroke.1 One of the key recommendations was that comprehensive discharge plans be developed in collaboration with the patient and carer prior to discharge, with a copy provided to them. This plan may include relevant community services, self-management strategies (such as information on medication, goals and therapies to continue at home), stroke support services, any further rehabilitation or outpatient appointments and an appropriate number to contact for any questions.

The National Stroke Audit - Rehabilitation Services Report is a biennial audit of Australian stroke rehabilitation services and accounts for the care of around 90 per cent of all patients provided with inpatient stroke rehabilitation in Australia. In 2016, the report showed that despite pockets of best practice, the quality of stroke rehabilitation had stagnated and there was enormous variability in care. It suggested that around half of all patients were discharged without vital education about lifestyle behaviours, which is essential to preventing further strokes.2

The audit found that at St George Hospital, only 67 per cent of patients had received a collaboratively developed discharge care plan prior to discharge. This put St George Hospital below the national average of 78 per cent and the state average of 77 per cent. A patient satisfaction survey of discharged stroke patients conducted in August 2017 also identified that patients were unaware of their discharge plans and did not receive information to support a safe and supported discharge.


  • An Allied Health Discharge Care Plan was developed in collaboration with allied health disciplines in the Rehabilitation Unit at St George Hospital.
  • This plan was reviewed and updated following each Plan Do Study Act (PDSA) cycle.
  • An allied health care coordinator role was established, to provide patients with a smooth and supported transition out of hospital. A workplace instruction was developed, outlining their roles and responsibilities.
  • A rehabilitation share drive was established, to allow interdisciplinary access to the Allied Health Discharge Care Plan and make it easier for staff to complete.
  • A rehabilitation sticker outlining the patient’s rehabilitation plan was produced and added to clinical notes and documentation, to ensure it was highly visible during auditing. Education was provided to staff on how it should be applied, to allow for easier auditing in the future.


Implementation – The project has been implemented and is currently undergoing final evaluation.


July 2017 - April 2018

Implementation sites

6W Rehabilitation Ward, St George Hospital, South Eastern Sydney Local Health District


Clinical Excellence Commission. Clinical Leadership Program


The project will be evaluated in 2018, by auditing the clinical records of stroke patients discharged from St George Hospital. Preliminary results from March 2018 show that:

  • over 90 per cent of Allied Health Discharge Care Plans had all sections completed
  • 100 per cent of staff were satisfied with the new processes, including the coordinator role and shared drive
  • 100 per cent of medical records were supported with correct documentation.

Lessons learnt

  • Rehabilitation staff are open to changing their practice to improve outcomes for stroke patients.
  • There were challenges in developing a tailored local care plan while using a district-wide electronic medical record system.


  1. Stroke Foundation. Clinical Guidelines for Stroke Management 2017. Melbourne VIC: InformMe; 2017.
  2. Stroke Foundation. National Stroke Audit Rehabilitation Services Report 2016. Melbourne VIC: InformMe; 2016.

Further reading

  • Gonçalves-Bradley D, Lannin NA, Clemson LM et al. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016;1:CD000313. DOI: 10.1002/14651858.CD000313.pub5


Lauren Stanwell
Senior Rehabilitation Physiotherapist
St George Hospital
South Eastern Sydney Local Health District
Phone: 02 9113 3601


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