Going home after a stroke: Preparing for the transition from rehabilitation

One of the biggest milestones after a stroke is when patients return home.

The transition home does not mean patients have completed their recovery or rehabilitation. Rather, it represents an important next step in their stroke recovery that comes with both progress and new challenges.

Preparing for a successful return home starts before patients leave inpatient rehabilitation. Their rehabilitation and medical team will assess their abilities, needs, home environment and available support to develop a transition plan that positions patients, as well as their families and caregivers, for success.

Once home, patients can continue their rehabilitation, working toward their recovery goals and adjusting to new everyday routines following stroke.

In this article, you will learn more about how rehabilitation helps patients and families plan for and support the transition home, how patients can continue their post-stroke treatment through outpatient rehabilitation and what to expect once patients return home.

Preparing for discharge after stroke rehabilitation

As patients continue to recover after stroke, their rehabilitation team will monitor their condition and progress and work with families and caregivers to determine a safe and appropriate discharge timeline.

Discharge planning may consider several factors:

• Assess current mobility and ability to complete everyday activities
• Examine the home environment for safety and accessibility
• Assess communication and cognitive abilities
• Work with physicians to determine medical and medication needs
• Determine the amount of supervision or assistance needed to transition home, based on medical, physical, functional and cognitive needs
• Work with families and caregivers to identify the appropriate level of caregiver availability and support for being safe and successful at home
• Prior to going home, ensure patients have necessary assistive devices or equipment
• Provide referrals, as needed, for follow-up physician care or additional outpatient rehabilitation

Families and caregivers may also receive additional education or training to ensure patients receive proper assistance at home.

Patients, families and caregivers should not hesitate to ask questions throughout the process to understand the care plan, medication instructions, next steps for post-stroke treatment and rehabilitation, and who to contact with questions or concerns after discharge.

Going home does not represent a return to full independence or complete recovery, but it is a major step in returning to life after a stroke.

Preparing your home after a stroke

Before returning home after a stroke, it is imperative to ensure the home environment accounts for changes in patients’ mobility, balance, vision or cognition resulting from stroke. This will ensure they can move around and perform everyday activities safely.

Families and caregivers may need to help patients and prepare areas in the home ahead of time to ensure a strong transition home:

• Entryways and stairs must be navigable if patients require a wheelchair or assistive device
• Walking paths should be wide and clear of any potential tripping hazards or clutter
• Bathrooms should be safe, easy to navigate and accessible with modifications or assistive devices installed as recommended
• Bedrooms and sleeping arrangements should account for patients’ needs and abilities following their stroke, as well as account for family members or caregivers staying in the home
• Homes should have proper lighting and visibility to ensure patients can navigate safely
• Patients, whether on their own or with assistance, should be able to move between commonly used areas within their home
• Patients should have access to frequently used items, accounting for any limitations in their mobility or reach

Before patients return home, an occupational therapist or rehabilitation professional can help them and their families identify potential challenges with the home environment and recommend modifications to improve the environment based on their needs. Read more about how occupational therapy supports stroke recovery.

Not all stroke survivors need the same things in their home.

Consulting with an occupational therapist or rehabilitation professional can help ensure home modifications are made with patients in mind.

Equipment and assistive devices you may need at home

Stroke patients returning home may need additional equipment or assistive devices to support their mobility, safety or ability to perform everyday activities.

Equipment can assist patients in several areas, depending on the effects of their stroke:

• Mobility devices, such as walkers, canes or wheelchairs, can help patients move around in their home and in the greater community
• Bathroom safety equipment like grab bars, modified toilet seats or shower chairs help ensure patients can use their bathroom safely
• Transfer or positioning equipment, including lifts or boards, can help safely transfer patients from a bed to a chair, onto the toilet or into the shower
• Orthotics or other supportive devices, such as prescription footwear or braces, can support patients’ mobility and assist with pain management; Good Shepherd’s Brace Clinic can support patients in this area
• Adaptive tools, such as modified silverware, sock aids or reach extenders, can help stroke patients dress, eat and access items within their homes; some of these tools can be customized and 3D-printed by Good Shepherd’s 3D Printing Lab.

Occupational therapists or other members of the rehabilitation team will recommend equipment and assistive devices that account for patients’ abilities, environment and goals for living in the home. They may also help train patients and caregivers on how to use the equipment properly before discharge.

Make sure the equipment meets patients’ needs. Obtaining appropriate and properly fitted equipment under the guidance of the rehabilitation team, rather than selecting it from a general list, can help support a safe return home following a stroke.

Continuing rehabilitation after returning home

Returning home after inpatient rehabilitation does not necessarily mean patients have completed their stroke recovery.

Their rehabilitation team can help patients identify options for continuing stroke rehabilitation at home. This could include home-based rehabilitation, where therapists come to their home, or outpatient rehabilitation at a location outside of the home.

When it comes to outpatient rehabilitation, you always have the right to choose your provider.

Outpatient rehabilitation can include physical, occupational, speech and/or vision therapy.

• Outpatient physical therapy continues to help patients build strength and improve mobility in the home and in the community. Read more about physical therapy’s role in stroke rehabilitation.
• In outpatient occupational therapy, patients continue building fine-motor skills and developing adaptive strategies to maximize self-care and participation in everyday activities. Read more about how occupational therapy aids stroke recovery.
• Outpatient speech therapy helps patients address skills and develop strategies to communicate more effectively both at home and in social settings. It can also address continued swallowing needs. Read more about how speech therapy supports stroke rehabilitation.
• Speech therapy can also continue addressing cognitive changes patients experience after a stroke. To learn more, read about cognitive and emotional changes after a stroke.
• Vision therapy can continue to help patients adjust to changes and deficits they may have experienced around their stroke that may affect their independence. Read more to learn about how strokes can affect vision.

During outpatient rehabilitation, patients can continue to work on goals started during inpatient stroke rehabilitation or address new needs or challenges that arise as they begin to re-engage with their day-to-day activities.

Adjusting to everyday life at home

Patients can expect that life might look different once they return home after stroke.

They may encounter new challenges in a home environment that were not apparent while in a more structured inpatient rehabilitation environment. Meanwhile, patients may need to learn new routines and strategies for managing everyday activities because of lasting physical, communication or cognitive changes caused by their stroke.

• Patients may need observation or assistance with personal care activities like bathing, dressing or managing medication or household activities, such as cooking, cleaning or laundry.
• Patients may need someone to help them track or schedule their appointments or manage their daily schedule.
• Patients may require assistance or observation to move safely around their home, which could include assistance with transfers in and out of bed.
• Patients may need someone to drive them or accompany them to appointments, as well as other community activities to ensure they can attend safely.
• As a result of cognitive changes, patients may need assistance communicating with others or engaging in social interactions.
• Post-stroke weakness and the addition of new routines can amplify fatigue, so patients may need someone to help monitor their stamina and daily activity.

Patients, families and caregivers should not just return to pre-stroke routines but instead follow the rehabilitation team’s recommendations, guidance and strategies for helping patients adjust to returning to everyday life.

Preparing family and caregivers for the transition home

Family members and caregivers play a pivotal role in helping stroke patients return home.

Caregivers will need to communicate with the medical and rehabilitation teams to understand what patients can do independently and where they will need assistance. Caregivers also must understand any special instructions to ensure patients are safe and cared for properly after discharge.

During discharge planning, caregivers and family members may receive training on assistive devices for mobility and everyday activities if patients have them, how to support them with everyday activities and how to communicate with them effectively if there are cognitive changes.

Returning home after a stroke is not just an adjustment for patients, but for caregivers and families as well. Caregivers and family members should feel comfortable knowing who to ask when they have questions or need guidance following discharge.

Additionally, caregivers should know where they can seek additional support if patients need assistance that goes beyond their capacity. Caregivers and family members must keep their own abilities and well-being in mind, as someone cannot care for others if they do not care for themselves. See our guide for more information on caring for someone after a stroke.

Returning home after a stroke is a big step that impacts not just patients, but their entire support system.

Stroke rehabilitation and continued recovery at Good Shepherd

When patients return home after their stroke, the medical and rehabilitation team must consider their needs, goals, abilities and support system. Discharge planning supports the overall rehabilitation journey by preparing patients and their caregivers for continued recovery after inpatient stroke rehabilitation.

At Good Shepherd, your care manager will work with you throughout the discharge process to help you and your family feel prepared, answer questions, and direct you to appropriate resources. Through our Safe Landing Program, we check your home and identify simple ways to reduce fall risk and maximize safety. We will also assist with basic set-up of walking and bathroom equipment to help you feel safe, confident and ready for the next step in your recovery.

When you are discharged from Good Shepherd Rehabilitation Hospital, your physician and nurses will meet with you and your family to discuss care needs. Meanwhile, your therapy team will discuss discharge instructions and home exercises. Once you are home, our Transitional Care Management program follows up with you at home and coordinates care with your primary care and Good Shepherd physicians.

Meanwhile, our Wheelchair Seating and Mobility Clinic can help patients identify appropriate mobility devices to maximize their independence. Meanwhile, our 3D print lab inside the Empower+ Makerspace in Center Valley, Pa., can help custom-produce tools that help patients participate in everyday activities.

If outpatient rehabilitation is the next step, we have 20 outpatient locations in eight counties across eastern Pennsylvania to help patients focus on long-term independence.

Take the next step in your stroke rehabilitation journey today.

You can also call 1-888-447-3422 (44-REHAB) or contact us online.