By Jeanie Davis

After acute care, a stroke patient’s discharge plan should include an inpatient rehabilitation facility (IRF) when they meet specific medical criteria, according to the 2016 American Heart Association/American Stroke Association guidelines.

Stroke also tops the CMS 13 list, which designates 13 medical conditions that 60% of an IRF’s patients must have for the IRF to qualify, says Dina Walker, RN, MSN, ACM, RN-BC, National Director of Case Management for Encompass Health. (The CMS IRF fact sheet is available online at:

IRFs provide hospital-level care to stroke patients who need intensive, interdisciplinary rehabilitation care provided under the direct supervision of a physician. The benefit of an IRF, says Walker, is the team’s high level of accountability and specialized training to care for the complex needs of stroke patients, including skin care, dysphagia, management of spasticity, depression/anxiety screening, progressive and intensive training in mobility, and activities of daily living (ADLs).

“In an inpatient rehabilitation setting, patients have physical, occupational, and speech therapies available to them for intensive therapy,” she explains. “It’s not unusual for stroke patients to require all three therapy disciplines. The overall goal is to improve the patient’s function and prepare the patient and their family or caregiver for return to home and back to the community so they can get back to doing things they enjoy.”

Outcomes data drive the treatment planning, which guides patients toward optimal recovery, Walker explains. A team approach to goal-setting involves the patient and family starting on day one. When discussing goals, the therapists relate the goals to the specific treatment or exercise so it is more relevant to the patient.

“Our therapists and nurses are excellent coaches, constantly cheering the patient on, reminding them of progress made from day to day,” says Walker.

Weekly team conferences, daily physician visits, and routine visits by a physician are in the patient’s treatment plan. Top priorities are bowel/bladder, pain and spasticity control, and intensive therapy to help patients improve their functional abilities and mobility.

Appropriate use of pain medication is a focus to avoid side effects, including oversedation, constipation, urinary retention, and potential addiction. The team may use alternative pain treatments such as repositioning, frequent rest breaks, identifying the appropriate equipment, mindfulness, and possibly holistic measures such as acupuncture. Spasticity is addressed with specific medications (yet avoiding side effects), and using movement, Botox/phenol blocks, and orthotics.

Patients undergo physical, occupational, and speech therapy every day, depending on how much therapy they can tolerate, explains Walker. CMS requires three hours of therapy five days a week. “Inpatient rehab is pretty intensive, so the patient should be willing and able to participate in rehabilitation,” Walker adds. “If the patient is especially debilitated and cannot tolerate the five-day schedule, the therapist may recommend stretching the therapy regimen over seven days instead of five so it is not too intensive in the very beginning of their stay. Then, as the patient’s endurance improves, they can gradually transition into a more intensive program.”

“Therapists are trained to deal with the cognitive and behavioral aspects of a stroke, always looking for signs that can indicate depression,” says Walker. “Stroke is a perfect example where it’s necessary to treat the whole person, not just the disease, because a stroke has such wide-ranging effects on the person.”

Avoiding readmissions is a primary goal. Depression is a leading cause of post-discharge readmission, so the team is keyed into that. “When patients are depressed, they are less likely to take care of themselves, may not take their medicines, and this can lead to a downward spiral,” she explains.

In addition, the team must identify and address risk factors for unnecessary ED visits and acute inpatient readmission, says Walker. Causes can include high blood pressure, urinary retention, dehydration, medication, skin breakdown, pneumonia, depression, constipation, falls, pain — and another stroke.

Average length of stay in an IRF can vary for stroke patients. “If the stroke is pretty severe, the team will be working on so many things with them. In general, the length of stay may be 14 or 15 days,” she says. “Our hope is always that these deficits are temporary, and as their brain heals, the impacted body functions will also heal,” Walker says. “But it takes time, and it depends on the severity of stroke and where it was in the brain.”

For many stroke patients, the prognosis is excellent and they can return to their lives “close to normal,” she adds. “For some, recovery can take longer. Sometimes, it can take years.”

Walker prefers the term “transition” instead of “discharge” planning. “Discharge implies the patient is gone and our job is done, and we just don’t work that way. We are always here for them. We are always available to help, even after discharge,” she explains.

She outlines the following steps in a transition plan:

• Identify the primary caregiver. “If someone hasn’t said ‘it’s me,’ you must ask,” says Walker. “You can’t assume the daughter will be the one to help because you’ve been talking to her during the hospitalization. She may be leaving town two days after discharge. You may have a gap in care at that point. Never assume, always ask: ‘Will you be the one to help care for them once they get back home?’”

Follow up with: “‘How long each day can you stay? Will you be there a few hours, all day, or just pop in and visit?’” says Walker. “You may identify more gaps based on these answers, and you must plan for those gaps.”

• Determine any ongoing rehabilitation needs. “Be specific and prescriptive,” says Walker. “You can’t just have a blanket order for home health that says ‘evaluate and treat the patient’ because that evaluation and planning takes time. When the patient is ready to go home, there isn’t the luxury of time. Those things have to be in place already, as much as possible.”

• Order appropriate equipment and devices. What will the patient need for ADLs and mobility? Consult with physical and occupational therapists.

• Plan for home modifications. Does the patient have balance issues and need grabbers installed? “The sooner you get this underway, the better,” says Walker. The case manager also may need to identify financial resources to cover these needs, she adds.

• Involve a social worker. Stroke patients will need someone who can work ahead of the patient’s discharge. Social workers provide counseling and coaching. “We’re treating the whole patient,” says Walker. “Think about that stroke patient, their level of function, what their life was like before the stroke, and what they will need to regain their function and some semblance of normalcy.”

If the patient stayed in acute care and an IRF, consider that this patient may have been away from home for possibly two months after an acute stroke. “That patient has the potential to be overwhelmed with their life,” says Walker. “They will have stacks of bills and mail, rotten food in the fridge, might come home to a dead plant or pet. If you add all of that on top of limitations because of their disease process, that is quite overwhelming.”

A social worker can help smooth the way for transition home. They can arrange any coaching, counseling, or community resources the patient will need.

• Educate the patient and caregiver on how to prevent another stroke, manage chronic comorbidities, and challenging medication regimens. “The medication regimen can be very complex, and is a huge factor to consider in avoiding a readmission,” Walker says.

• Ask the home care agency for a same-day admission or admission within 24 hours of discharge. “Try to have a nurse and therapist at the home when the patient arrives. How much stress and anxiety would that alleviate for a patient and their caregiver?” says Walker.

• Set up timely follow-up appointments within three to five days post-discharge. Walker suggests coordinating care with the patient and caregiver. “You’re modeling the behaviors they need to learn to self-manage their healthcare needs — how to handle those calls, how to get past barriers, the words to use, who you spoke to,” Walker explains. “Don’t coordinate all the care from your office; show them how to do it. It helps so much.”

• Complete a care transition document for each patient. “This is a concise document that contains important details about that patient and why we think the patient is high-risk for readmission,” says Walker. It includes the transition plan that the case manager has initiated, as well as key follow-up: outstanding labwork, radiology tests, or other diagnostic testing.

• Review and educate the patient and caregiver on community resources, including a stroke support group. Several Encompass Health rehabilitation hospitals are designated Stroke Centers of Excellence. As part of that designation, that IRF must coordinate stroke support groups.

“Don’t just give patients a list of resources,” says Walker. “Identify who could help the soonest, start the referral, and get them on the list. Many community resources have lists of people in need, so get your patient on the list as soon as possible so to minimize their wait time for services. Plead your patient’s case for them and get them moved up on the list, if possible.”

“Be a proactive patient advocate,” she says. “Start the process right away and make the referrals.”