Transitioning to the Next Stage

Discharge from the hospital

Your time in the hospital may vary, anywhere from 24 hours to a few days or sometimes even a few weeks if you are very ill. However, it is always a good idea to start planning for the next step early. We want to make sure that your transition out of the hospital is as smooth as possible, but the process can be complicated. To help navigate it, the Case Manager assesses your preferences and needs alongside our physicians, nurses, and therapists. Bringing all of this information together, the Case Manager then searches or arranges for needed rehabilitation services.

While everyone generally prefers to go home as soon as possible, this is often not feasible if your neurologic symptoms or deficits prevent you from accomplishing your usual routines safely. The following are common discharge destinations:

  • Home – If you quickly recovered from your symptoms, you may be able to go straight home from the hospital. However, it is a good idea to have family or friends available to help at a moment’s notice in case you develop recurrent or new symptoms. Also, sometimes symptoms develop later, so it is important to go to your first appointment in the Stroke and Cerebrovascular Diseases Clinic to be reassessed or to call the Stroke Coordinator who can help put you in touch with a doctor or nurse.
  • Home with services – If you are well enough but have some residual neurologic deficits, you may be able to return home with a visiting nurse who can guide you in physical, occupational, or speech therapies. These visits may be as often as once a day at the beginning and then spread out to once or twice per week.
  • Acute rehabilitation hospital (“acute rehab”) – If your symptoms or deficits are severe, we ideally want you to go to an acute rehabilitation hospital. These facilities are staffed by physical, occupational, and speech therapists as well as physicians and nurses. Most facilities try to schedule at least a few hours of rehab therapies per day. The best rehabilitation facilities for stroke patients are neurology-specific rehabs with dedicated neurologists and physiatrists as well as PTs, OTs, and speech therapists who are experienced with stroke patients. Being close to home can be helpful for supportive family members, but getting you the best rehabilitation services should take priority whenever possible.
  • Skilled nursing facility (“SNF”) – If your symptoms or deficits are severe but you are limited in your ability to participate in rehabilitation therapies at this time, you may go to a skilled nursing facility. These facilities can provide physical, occupational, and speech therapy, but the duration of time spent on therapy is usually only an hour or so per day. These facilities are tailored more towards supporting and allowing your brain and body more time to heal from being very sick with the hope that you will be able to participate more in rehabilitation therapies at a later time.
  • Long term acute care facility (“LTAC”) – In some cases, you may be very sick and require critical care level support (breathing support, feeding support, intravenous medications, etc.). In these cases, the recovery phase may be more prolonged and require that you continue these supportive measures, sometimes for weeks or months. A long term acute care facility can provide this intensive level of support while also giving you time to heal, similar to a SNF. 

Common questions to ask your doctor or nurse

  1. Have you prescribed me any new medications?
  2. Have you changed any of my old medications?
  3. Do I need to pick up the medications at my pharmacy before going home?
  4. Which neurologist should I see in the clinic? When is that appointment?
  5. How do I get to the Comprehensive Stroke Clinic?
  6. When should I see my primary care physician?
  7. Are there any tests I should schedule after I leave the hospital?
  8. Should I change my diet?
  9. Am I allowed to exercise after I leave the hospital?
  10. Can I go back to smoking or using tobacco after I leave the hospital?
  11. If I have questions after the hospitalization, who should I speak to?