Leaving Rehabilitation
Recovering from a stroke may take longer than just the process spent in active inpatient rehabilitation. After leaving inpatient rehabilitation, the stroke patient still works with the physiatrist.
Community Re-entry
It is important to have a smooth transition from the hospital to the community. UPMC South Side offers community re-entry activities to help practice newly learned skills in “real life” situations. Examples of community re-entry activities can include going out for lunch or going shopping. The patient care team establishes goals for the outing. During the trip, problems can be identified; solutions can be addressed during therapy sessions.
Getting out in the community can improve symptoms of depression and overall recovery from a stroke.
Discharge Planning After a Stroke
Patients and families should start planning for discharge as soon as possible. Services may take time to arrange; the case manager or social worker can help provide more information on what services are available.
Those services may include:
Outpatient rehabilitation
- Outpatient rehabilitation may include physical, occupational and speech-language therapy. It is provided at an outpatient clinic or center. Most insurance plans cover some of the care.
Adult day care
- This is where an individual receives care in a group setting. The cost may or may not be covered by insurance. The case manager or social worker can provide a list of adult day programs and information on these services. There are waiting lists for some programs and medical clearance may be needed.
Home health care
- Home health care may include therapy and nursing visits that happen in the home. The care usually is done in a short visit and is not around-the-clock care. Most insurance plans cover home health care.
Personal care homes or assisted living communities
- This setting includes small residences where only a few individuals receive care and campus-like settings for people with various needs. This care usually is not covered by insurance.
Skilled nursing homes
- Nursing care is available around-the-clock. Therapy usually is available. Insurance may cover costs.
Private duty nursing
- Provides care ranging from several hours a day up to around-the-clock care. May need to be arranged several days before discharge. Insurance usually doesn’t cover this type of care.
Creating a Portable Health Profile
A portable health profile is a record that includes basic information about the patient. The profile lets the patient have all the information they need in one place. They can easily access it anytime they visit the doctor, are hospitalized, or go for outpatient services. Having updated health information lets the clinician give more accurate and efficient care to the patient.
The patient or caregiver should update the profile anytime the patient’s medical situation changes. Those changes include new conditions, changes to medications, and new health providers. That information may include allergies, emergency contact information, insurance information, and advance directives.
Profiles can either be hand written or typed. The health care team can provide patients and caregivers with sources of electronic profiles if that is the method they choose to use. Companies that offer an electronic profile usually charge a fee.