Management and Rehabilitation of Stroke Across Care Settings Through Interdisciplinary Approach.[1]

Individualized comprehensive assessment and plan of care but a collaborative, holistic, and interactive approach of the interdisciplinary team is the uniqueness of stroke management and rehabilitation. This multidisciplinary team in the various care settings may include the patient, family members/primary caregiver, physician(MD), nurse, physical therapist(PT), occupational therapist(OT), a speech-language pathologist(SLP), social worker(MSW), and orthotist.

The following CMAP shows the roadmap of a stroke care setting. It starts from the hospital and ends in the home. For an elderly or disabled person, a home is where he/she lives permanently and can be a long term nursing facility, independent living facility(ILF), or an assistive living facility(ALF)

The table below shows the length of stay in various care settings and a beginning timeline. Sources[2] [3] [4] [5]

Care Setting	Timeline for the Admission	Average Length of Stay	Multidisciplinay Team
H; Emergency(E)	Onset to a few hours	A few hours	MD, RN.
H; Intensive Care Unit(ICU)	After E	5 hours – 5 days	MD, RN, OT, PT
H; Acute Care Unit(ACU)	After ICU	2 days – 2 weeks	MD, RN, OT, PT, SLP, MSW
H or outside the H SNF; Subacute Rehab	After ACU	1 week – 3 weeks	MD, RN, OT, PT, SLP, MSW
SNF; Long term Rehab under Medicare A	After subacute rehab or can continue after acute care DC	Up to 100 days after DC from the H	MD, RN, OT, PT, SLP, MSW,
Long term care in an SNF	After DC from Medicare A	Until the patient has reached max rehab potential or until the insurer stops	MD, RN, OT, PT, SLP, MSW, Orthotist
Home Health Care; In a home, ILF or ALF	After DC from H or SNF or an order from the MD for homebound patients.	Until the patient has reached max rehab potential or the insurer stops, or the patient is no longer homebound.	MD, RN, OT, PT, SLP, MSW, Orthotist,
Outpatient Rehab; could be a stand-alone clinic or in an ILF/ALF	After DC from H or SNF or an order from the MD.	Until the patient has reached max rehab potential or the insurer stops	MD, OT, PT, SLP, Orthotist,

References

---

[1] Miller, E. L., Murray, L., Richards, L., Zorowitz, R. D., Bakas, T., Clark, P., & Billinger, S. A.. (2010). Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient. Stroke. Stroke. http://doi.org/10.1161/str.0b013e3181e7512b

[2] Langhorne P, Taylor G, Murray G, Dennis M, Anderson C, Bautz-Holter E, Dey P, Indredavik B, Mayo N, Power M, Rodgers H, Ronning OM, Rudd A, Suwanwela N, Widen-Holmqvist L, Wolfe C. Early supported discharge services for stroke patients: a meta-analysis of individual patients’ data. Lancet. 2005; 365: 501–506.

[3] Lee WC, Christensen MC, Joshi AV, Pashos CL. Long-term cost of stroke subtypes among Medicare beneficiaries. Cerebrovasc Dis. 2007; 23: 57–65.

[4] Wodchis WP, Teare GF, Naglie G, Bronskill SE, Gill SS, Hillmer MP, Anderson GM, Rochon PA, Fries BE. Skilled nursing facility rehabilitation and discharge to home after stroke. Arch Phys Med Rehabil. 2005; 86: 442–448.

[5] Worsowicz G, Deutsch A, Heinemann A. Integrating financial data into inpatient rehabilitation health services research. Arch Phys Med Rehabil. 2008; 89: e27.

---