ABSTRACT
Every patient leaves the hospital. Preparing for discharge begins prior to planned admissions and on presentation to the hospital for unplanned admissions. Professional team members collaborate, guiding the patient/caregiver through the hospitalization to transition. Interprofessional team members gather daily to discuss each patient's progress toward discharge goals. Professionals present their perspectives on progress as well as their opinions regarding transition disposition that is safe and will provide the patient with the best opportunity for an optimal long-term outcome. Neuroscience patient transition options include home, assisted living, skilled nursing facilities, inpatient rehabilitation (IR), and long-term acute care hospital (LTACH). Coordinating a smooth transition also involves communication with the receiving primary care and specialty providers. Implementing processes to assure counseling/education are provided, the importance of the specialization of neuroscience interprofessional team members, and ongoing communication will break down a complex health-care event to a positive experience for the patient and his or her caregiver.
