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 SettingTimeline for the AdmissionAverage Length of StayMultidisciplinay Team
H; Emergency(E)Onset to a few hours A few hoursMD, RN.
H; Intensive Care Unit(ICU)After E5 hours – 5 daysMD, RN, OT, PT
H; Acute Care Unit(ACU)After ICU2 days – 2 weeksMD, RN, OT, PT, SLP, MSW
H or outside the H SNF; Subacute RehabAfter ACU1 week – 3 weeksMD, RN, OT, PT, SLP, MSW
SNF; Long term Rehab under Medicare AAfter subacute rehab or can continue after acute care DCUp to 100 days after DC from the HMD, RN, OT, PT, SLP, MSW,
Long term care in an SNFAfter DC from Medicare AUntil the patient has reached max rehab potential or until the insurer stopsMD, RN, OT, PT, SLP, MSW, Orthotist
Home Health Care; In a home, ILF or ALFAfter 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/ALFAfter DC from H or SNF or an order from the MD.Until the patient has reached max rehab potential or the insurer stopsMD, OT, PT, SLP, Orthotist,
H: Hospital   RN: Nurse   SNF: Skilled Nursing facility   DC: Discharged  


[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.

[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. Lancet2005; 365: 501–506.

[3] Lee WC, Christensen MC, Joshi AV, Pashos CL. Long-term cost of stroke subtypes among Medicare beneficiaries. Cerebrovasc Dis2007; 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 Rehabil2005; 86: 442–448.

[5] Worsowicz G, Deutsch A, Heinemann A. Integrating financial data into inpatient rehabilitation health services research. Arch Phys Med Rehabil2008; 89: e27.

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