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Post-Stroke Resources and Community Reintegration

presented by Michelle Camicia and Barbara Lutz

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Financial: Barbra Lutz is funded as a co-investigator through patient-centered outcomes research institute (PCORI) and national institutes of health. Michelle Camicia is funded by the Gordon and Betty Moore Foundation and the Rehabilitation Nursing Foundation


 Non-Financial: Barbra Lutz and Michelle Camicia have no competing non-financial interests or relationships with regard to the content presented in this course.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

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Transitioning home and adapting to life after stroke is often difficult for stroke survivors and their family caregivers. Successful recovery and community reintegration is dependent on stroke survivors and their family members being able to adapt to the post-stroke changes in their lives. They often do not have working knowledge of community- or web-based resources that may be available to help them adjust to new limitations and changes in roles and responsibilities. Members of the interprofessional team can facilitate post-discharge adaptation by anticipating the needs of the stroke survivor and family members and linking them to the most appropriate resources. This course focuses on describing the post-discharge needs of stroke survivors and their family caregivers, assessing post-discharge needs, and identifying resources that can facilitate recovery and successful community reintegration post-stroke. Examples of community- and web-based resources are provided.

Meet Your Instructors

Michelle Camicia, PhD, MSN, RN, CRRN, CCM, NEA-BC, FAHA

Michelle Camicia, PhD, MSN, CRRN, CCM, NEA-BC, FAHA, is the Director of Operations for Kaiser Foundation Rehabilitation Center at the Vallejo Medical Center. She is responsible for day-to-day operations of the Center as well as outreach, quality, and regulatory oversight. Michelle is a past president of the Association of Rehabilitation Nurses. She has participated in…

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Barbara Lutz, PhD, RN, CRRN, APHN-BC, FAHA, FNAP, FAAN

Dr. Barbara Lutz is the McNeill Distinguished Professor at the University of North Carolina-Wilmington School of Nursing. Her 30+ year career as a rehabilitation and public health nurse spans practice, research, education, and service. Her research focuses on understanding the needs and experiences of patients with stroke and other chronic illnesses and their family caregivers…

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Chapters & Learning Objectives

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1. Post-Discharge Needs of Stroke Survivors and Family Caregivers

Family-centered care requires that the health care team identify and address the needs and concerns of patients and their families. In this chapter, the most common post-discharge needs of stroke survivors and their caregivers are discussed to help nurses, therapists, and other health care providers recognize these needs in order to better tailor care plans for post-discharge support and follow-up.

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2. Assessing and Addressing Post-Discharge Need

A systematic and comprehensive assessment can help identify post-discharge needs and establish priorities for referrals and follow-up care. In this chapter, the elements of a comprehensive assessment are discussed and strategies for working with stroke survivors and family members to prioritize follow-up care are recommended.

3. Community Reintegration and Resources Addressing the Long-Term Needs of Stroke Survivors and Their Families

Stroke survivors and their family members are often unaware of available community and web-based resources that can provide support and facilitate community reintegration post-stroke. In this chapter, community- and web-based resources addressing the post-discharge needs of stroke survivors and their family members will be described. Novel programs and resources that nurses, therapists, and other health care providers might consider implementing in post-discharge stroke care will be discussed.

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This course gives students an overview of the nurse’s role in facilitating care transitions for stroke survivors from acute care to post-acute care to optimize outcomes for the patient and family. Specific risk factors associated with poor transitions are presented. Participants will learn nursing interventions to optimize care transitions for stroke survivors. A brief review of evidence-based models of care transitions across the post-acute continuum will be provided.

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Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Approximately one-third of those hospitalized with stroke are under the age of 65. African Americans are approximately twice as likely to experience a stroke at a younger age when compared to Whites. The needs of younger stroke survivors are often very different from those of older stroke survivors. This course provides an overview of the prevalence of “young stroke.” The unique needs of young stroke survivors and their families are discussed, and recommendations for nurses and other health care providers for identifying and addressing the needs of younger stroke survivors are highlighted. Examples of novel programs for young stroke survivors are included.

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Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
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