Key Performance Indicators

KPI 11

A binding, personalised, and documented rehabilitation and sector transition plan provided at the time of discharge to at least 60% of patients.

Current status

In most countries patients needing rehabilitations are transferred from the hospital stroke unit to rehabilitations institutions outside of hospital and often in the municipalities. To ensure that rehabilitation needs are met and communicated, a rehabilitation and sector transition plan provided at the time of discharge to at least 60% of patients (KPI 11). This KPI is met in Norway, Denmark, Austria, Bulgaria and Belarus based on high quality data sources, in 14 countries the KPI is met based on lower quality data sources. Not providing a rehabilitation plan to a stroke patient with need for rehabilitation means a delays in initiation or continuation of rehabilitation outside of the stroke unit. Lack of a plan also precludes access to life after stroke support, which inevitably causes uncertainty for the patient and carers about the immediate future after discharge.

National stroke plans are needed to define continuity of care, the trans sectoral planning of care and the level of care to be provided. A rehabilitation plan presented as a prescription defining deficits and needs at discharge ensures easy communication as well as the option of monitoring at patient level.