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Discharge Planning Checklist: Stroke Care and Rehabilitation

Stroke is the leading cause of adult disability. A stroke occurs when a blood vessel to the brain is either blocked by a clot or bursts/ruptures. When either of these things happens, brain cells begin to die and brain damage occurs.

Fast, effective treatment is key to recovery from a stroke. Experts sometimes say “time is brain” as quick treatment can save brain cells and reduce residual damage from the stroke. It is vital that you know the signs of a stroke and seek immediate treatment when those signs are present.

stroke symptoms for senior healthcare*From the National Stroke Association

After acute care treatment, the patient faces the recovery and healing process.  Rehabilitation should begin as soon as possible during this healing process. One third of stroke patients need help with activities of daily living after a stroke, and one quarter cannot ambulate without assistance. The most common effects of stroke are: speech impediment, decreased motor skill coordination, and depression. The nature and extent of disability after a stroke varies widely depending on the type of stroke and area of the brain that was impacted, as well as the course of rehabilitation.

Due to the nature of our brains, rehabilitation can be very effective in gaining back abilities, compensating and gaining new skills to be more independent–and the process can continue over a long period of time. The rehabilitation process will depend on many factors such as the nature of the stroke and resulting damage, the person’s overall health history and other diagnoses/disabilities, living situation/caregiver availability and more. Any good rehabilitation process is a coordinated team effort, involving the patient, family and various medical and rehabilitation providers.

The average length of stay for patients with an acute ischemic stroke is between 6-10 days in the acute care setting, so rehabilitation options must be evaluated quickly. Rehabilitation for stroke and other acute medical issues can occur in different settings. An acute care rehabilitation setting (inpatient in the hospital or a special hospital unit) may be advised for intensive therapy and acute/complex medical needs. This type of care is often appropriate for a stroke patient and may help extend the benefits of rehabilitation services (hospital/acute care falls in to one “bucket” under Medicare coverage, and rehabilitation/skilled nursing falls in to another “bucket” of coverage days).  Rehabilitation facilities offer different types of programs and levels of intensity. Some of these may be stand-alone short term rehabilitation centers, while others may be part of a hospital campus or long-term skilled nursing facility (i.e. many nursing facilities have long term and short term sections or mixtures of patients).

Discharge planning and the appropriate rehabilitation setting depend largely on the various factors that make up the patient’s situation. As an advocate for a stroke patient, it is vital you help communicate expectations and hopes for recovery and ask questions to ascertain the proper level of care, options and expectations for possible recovery and ongoing needs. With any medical crisis, but particularly in cases like stroke where the rehabilitation process can have long-term impacts on quality of life, consider involving an expert geriatric care manager as a professional patient advocate and care coordinator.

The National Stroke Association offers a fact sheet with an overview on choosing a stroke rehabilitation program, which you may want to review and save as you go through the discharge planning process.

We have created a “Discharge planning checklist for transition to rehabilitation” to help you with the key steps and questions when transitioning to an inpatient rehabilitation program after being hospitalized for a stroke, broken hip or any other acute care need requiring rehabilitation. This discharge planning checklist is a handy tool as you evaluate options and advocate for a good transition to help the patient have the most successful outcomes possible.

As the patient progresses through the rehabilitation process, the next steps will involve discharge planning for the longer term, whether the patient returns home living independently, with some support services, with a caregiver or home caregiver services, or moves to assisted living or a skilled nursing facility.  An ongoing prevention plan is essential to reduce the risks of recurrent stroke.  Patients should work closely with their medical team to understand modifiable risk factors and work to reduce them, as well as follow their personalized treatment plan (medications, diet, wellness/screenings and monitoring).

Need help or have questions?  Contact at 727-447-5845 or online.  Our expert patient advocates can help you:

  • Manage the hospitalization and advocate for the best use of services and benefits to maximize recovery;
  • Choose the best rehabilitation options;
  • Navigate your insurance and other benefits;
  • Coordinate the discharge plan and ongoing recovery;
  • Attend doctors’ appointments, serve as a liaison during your treatment and coordinate ongoing prevention;
  • Set up services according to your goals, wishes and needs.
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