EVALUATION OF DISCHARGE READINESS IN A PATIENT WITH SECONDARY STROKE: A CASE STUDY
DOI:
https://doi.org/10.60050/lkh.v9i2.73Keywords:
Discharge Readiness, Caregiver Preparedness, Stroke, ReadmissionAbstract
Background: Early readmission in stroke survivors remains a critical issue, particularly in patients with mild initial symptoms but who experience early recurrence within a short period. Evaluating both patient and caregiver readiness for discharge is essential to improve home care outcomes and prevent avoidable hospitalizations.
Objectives: This case study aims to assess discharge readiness in a post-stroke patient and their caregiver using the PATH-s instrument and examine its implications for readmission prevention.
Methods: A descriptive single-case study was conducted involving a 66-year-old male with a secondary ischemic stroke within 30 days of the initial attack. Data were collected via clinical records and interviews. Discharge readiness was evaluated using the Preparedness Assessment for the Transition Home after Stroke (PATH-s) instrument, consisting of 25 items. The assessment was guided through a structured interview due to the patient's limited ability to self-complete the questionnaire.
Results: The PATH-s assessment yielded a total score of 69 out of 100, indicating a moderate level of discharge readiness. The average score per item was 2.67 out of 4, suggesting a need for additional support in specific areas. The domains identified for improvement included financial capacity, home and transportation accessibility, long-term prognosis, and patient insight about stroke.
Conclusion: Evaluating discharge readiness in the patient and family caregiver helped increase awareness of home care limitations and guided appropriate nursing interventions. These findings highlight the value of structured assessments like PATH-s in supporting clinical decision-making and individualized discharge planning.
References
AS, K., & Tadi P. (2025). Cerebrovascular Disease. [Updated 2023 Aug 7]. In: StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK430927/
Camicia, M., Lutz, B. J., Harvath, T. A., & Joseph, J. G. (2021a). Using the Preparedness Assessment for the Transition Home After Stroke Instrument to Identify Stroke Caregiver Concerns Predischarge: Uncertainty, Anticipation, and Cues to Action. Rehabilitation Nursing, 46(1), 33–42. https://doi.org/10.1097/rnj.0000000000000267
Camicia, M., Lutz, B. J., Harvath, T. A., & Joseph, J. G. (2021b). Using the Preparedness Assessment for the Transition Home After Stroke Instrument to Identify Stroke Caregiver Concerns Predischarge: Uncertainty, Anticipation, and Cues to Action. Rehabilitation Nursing, 46(1), 33–42. https://doi.org/10.1097/rnj.0000000000000267
Camicia, M., Lutz, B. J., Joseph, J. G., Harvath, T. A., Drake, C. M., Theodore, B. R., & Kim, K. K. (2021). Psychometric Properties of the Preparedness Assessment for the Transition Home After Stroke Instrument. Rehabilitation Nursing, 46(2), 113–121. https://doi.org/10.1097/RNJ.0000000000000310
Chandola, T., & Rouxel, P. (2022). Home modifications and disability outcomes: A longitudinal study of older adults living in England. The Lancet Regional Health - Europe, 18, 100397. https://doi.org/10.1016/j.lanepe.2022.100397
Chen, M., & Che, C. (2024). Perceived social support, self-management, perceived stress, and post-traumatic growth in older patients following stroke: Chain mediation analysis. Medicine, 103(29), e38836. https://doi.org/10.1097/MD.0000000000038836
Elf, M., Norin, L., Meijering, L., & Suhonen, R. (2025). Rehabilitation at Home With the Development of a Sustainable Model Placing the Person ’ s Needs and Environment at Heart : Protocol for a Multimethod Project Corresponding Author : 13. https://doi.org/10.2196/56996
F, L., C, H., MZ, K. S., & Al., E. (2025). Ischemic Stroke. [Updated 2025 Feb 21]. In: StatPearls [Internet]. 499997. https://www.ncbi.nlm.nih.gov/books/NBK499997/
Gardener, H., Romano, J. G., Derias, T., Gutierrez, C., Asdaghi, N., Johnson, K., Gordon Perue, G., Marulanda, E., Brown, S. C., Foster, D., & Rundek, T. (2023). Early hospital readmission following stroke: the Florida Stroke Registry. Frontiers in Stroke, 2. https://doi.org/10.3389/fstro.2023.1238442
Guglielmi, V., Compagne, K. C. J., Sarrami, A. H., Sluis, W. M., van den Berg, L. A., van der Sluijs, P. M., Mandell, D. M., van der Lugt, A., Roos, Y. B. W. E. M., Majoie, C. B. L. M., Dippel, D. W. J., Emmer, B. J., van Es, A. C. G. M., Coutinho, J. M., Dippel, D. W. J., van der Lugt, A., Majoie, C. B. L. M., Roos, Y. B. W. E. M., van Oostenbrugge, R. J., … Ramos, L. A. (2021). Assessment of Recurrent Stroke Risk in Patients With a Carotid Web. JAMA Neurology, 78(7), 826. https://doi.org/10.1001/jamaneurol.2021.1101
Hollinghurst, J., Fry, R., Akbari, A., Watkins, A., Williams, N., Hillcoat-Nallétamby, S., Lyons, R. A., Clegg, A., & Rodgers, S. E. (2020). Do home modifications reduce care home admissions for older people? A matched control evaluation of the Care & Repair Cymru service in Wales. Age and Ageing, 49(6), 1056–1061. https://doi.org/10.1093/ageing/afaa158
Karki, A., & Manandhar, L. (2024). Understanding Ischemic Stroke: Symptoms, Risks, and the Importance of Timely Intervention. The American Journal of Patient Health Info, 1(2). https://doi.org/10.69512/ajphi.v1i2.61
kusuma Putri, T. antika rizki, Agustian, R. S., Hayati, S. N., Nurdiana, G., Retno Agustina, T. H., & Puspasari, S. (2024). The Effect of Structured Discharge on Family Readiness to Provide Transient Care for Stroke Patients. Jurnal Keperawatan Malang (JKM), 9(1), 100–108. https://doi.org/10.36916/jkm.v9i1.283
Lee, Y., & Won, M. (2022). Mediating Effects of Rehabilitation Motivation between Social Support and Health-Related Quality of Life among Patients with Stroke. International Journal of Environmental Research and Public Health, 19(22), 15274. https://doi.org/10.3390/ijerph192215274
Li, S., Chen, R., Zhang, L., Li, H., Gong, Y., Hang, Y., Cao, J., & Zhang, H. (2024). Relationships Between Quality of Discharge Teaching, Readiness for Hospital Discharge, Self‐Efficacy and Self‐Management in Patients With First‐Episode Stroke: A Cross‐Sectional Study. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.17481
Li, S., Jing, J., Li, J., Wang, A., Meng, X., & Wang, Y. (2023). Elevated hs-CRP and Symptomatic Intracranial/Extracranial Artery Stenosis Predict Stroke Recurrence after Acute Ischemic Stroke or TIA. Journal of Atherosclerosis and Thrombosis, 30(6), 63512. https://doi.org/10.5551/jat.63512
Li, X., Song, S., Jia, W., Shi, Z., Xie, L., Fan, M., & Li, C. (2025). Do CRP gene variants and smoking elevate recurrent stroke risk in minor ischemic stroke patients? European Journal of Medical Research, 30(1), 179. https://doi.org/10.1186/s40001-025-02355-3
Liu, C., Luo, L., He, X., Wang, T., Liu, X., & Liu, Y. (2024). Patient Readmission for Ischemic Stroke: Risk Factors and Impact on Mortality. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 61. https://doi.org/10.1177/00469580241241271
Melak, A. D., Wondimsigegn, D., & Kifle, Z. D. (2021). Knowledge, Prevention Practice and Associated Factors of Stroke Among Hypertensive and Diabetic Patients – A Systematic Review. Risk Management and Healthcare Policy, Volume 14, 3295–3310. https://doi.org/10.2147/RMHP.S324960
Posri, N., Srisatidnarakul, B., & Hickman, R. L. (2022). Development of a Readiness for Hospital Discharge assessment tool in Thai patients with stroke. Belitung Nursing Journal, 8(1), 75–83. https://doi.org/10.33546/bnj.1968
Qian, F. (2023). Factors Influencing Caregiver Burden among Family Caregivers of Post-Stroke Persons in Wenzhou, China. Nursing and Health Sciences Journal (NHSJ), 3(1), 24–31. https://doi.org/10.53713/nhs.v3i1.169
Tay, M. (2021). Hospital readmission in stroke survivors one year versus three years after discharge from inpatient rehabilitation: Prevalence and associations in an Asian cohort. Journal of Rehabilitation Medicine, 53(6), jrm00208. https://doi.org/10.2340/16501977-2849
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