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)
|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,|
 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
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 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.
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