What to Expect from Outpatient Rehab

Following a stroke, about two-thirds of survivors receive some type of rehabilitation. This is a time of both hope and anxiety for stroke families: hope that the survivor will make a good recovery; anxiety or fear about what happens next and what to expect.
Of course, the first priority after stroke is stabilizing the patient. Once a hospitalized survivor is medically stable, they may be moved to inpatient rehab. Inpatient rehab is sometimes referred to as acute rehab and requires at least three hours of therapy a day. The goal of inpatient rehabilitation is to return patients safely to their home environment. The average stay is 15 days, although some patients may stay less and others may stay longer. Patients not able to meet the requirements of inpatient rehab may be discharged to a skilled nursing facility.  After leaving inpatient rehab, survivors are typically discharged home.
“Once home, survivors may need ongoing therapy to continue to build their strength and return to the activities they pursued before the stroke,” said physical therapist Kim Brennan, administrative director of outpatient therapy and specialized services at Shirley Ryan AbilityLab in Chicago. In that case, survivors may be transitioned to outpatient rehab, either provided in an outpatient clinic or at home through a home healthcare agency. In outpatient therapy, survivors go into a rehab facility, which distinguishes it from home-based therapy. Prescriptions and insurance vary, but outpatient therapy is typically two or three hours, once or twice a week.
“Whether a patient is referred to inpatient or outpatient therapy depends on the level of medical care required,” said Brennan. “When a patient’s medical status can be managed and monitored without IVs, nursing care and the like, then the patient can be considered for outpatient rehabilitation.”
Outpatient or Home-based Therapy?
The decision of whether to use outpatient or home-based therapy depends on the survivor’s abilities. “If the patient demonstrates difficulty getting in and out of the home, he or she would be a better candidate for home health therapy until he or she is strong enough to regularly attend therapy in an outpatient clinic,” Brennan said. “Stairs can often be a barrier to transitioning out of the house for appointments or community events, and having a therapist come to the house to practice the stairs and negotiate the rest of the home environment can be helpful. Inpatient rehabilitation simulates these activities, but everyone’s home environment is unique and presents different challenges after stroke.”
“Whether a patient is referred to inpatient or outpatient therapy depends on the level of medical care required.” — Physical Therapist Kim BrennanHome therapy is not considered to be part of outpatient therapy; it is a separate level of care. Home health therapy is often recommended when a patient is homebound and may require continued nursing support for issues such as wound care, blood draws, etc., in addition to therapy care.
Bridging Levels of CareAt Shirley Ryan AbilityLab, they offer a program called Day Rehabilitation, which is a bridge from acute inpatient rehabilitation to outpatient therapy. “Day Rehabilitation provides patients with three-to-six hours of therapy three-to-five days per week with the primary goal of community reintegration,” Brennan said. “Upon discharge from this program, outpatient therapy may be considered if ongoing therapy is required.” Not all rehab hospitals have a program like this.
Types of Therapies in Outpatient FacilitiesOutpatient therapy may consist of occupational, physical and speech therapy. Recreational, art, and music therapy may also be offered during inpatient rehab or at a skilled nursing facility. Brennan says that they collaborate closely with their fitness center so that patients have the option to pursue a personalized exercise program with an exercise physiologist upon discharge.
Getting the Most Out of an Outpatient Therapy RxBrennan offered a few recommendations patients should consider for outpatient care:

• Of course, picking the right facility is key. In therapy, one size does not fit all. The most successful rehab is provided by a team of therapists who discuss the various needs of individual patients. Patients and their families need to be included as members of that team. So, a good question for stroke families to ask is “are we involved in patient-care plan discussions?”
• Finding the best providers for your condition is key, so it is important to call ahead to make sure the clinic has the specialists who fit your diagnosis. “What kind of therapy do you offer?”
• It is important to get one-on-one quality time with your therapist so that you can get the most out of each session and make quicker gains. Although group therapy can be beneficial in some instances, avoid situations where survivors are given only or primarily group therapy. Ask: “How much individual therapy will my survivor receive?”
• Patient-established goals are important. They should be set at the beginning of care and monitored regularly to ensure progress is being made. “Are you going to ask my father what his goals are and design his rehab program around those goals? How will they be monitored?”
• Communication is key! Open lines of communication with your provider around progress, goals and any barriers that may arise are important to ensure that you achieve the best outcome  Location shouldn’t be the only considerationIn most areas, there are more outpatient facilities than inpatient, and often stroke families chose a facility that is close to home. Brennan cautions that geographic location may not be the most relevant criterion: “It is very important to find the clinic that is best positioned to promote the quickest recovery and best outcome for the patient, regardless of location,” she said.
  The good news is that despite the inherent complexity of the stroke recovery process, rehab works, and families can expect to see improvement as their survivor recovers and orients to a new self. Carolee J. Winstein, Ph.D., P.T., the lead author of the American Stroke Association’s Guidelines for Stroke Rehabilitation and Recovery for Adults remains optimistic for stroke survivors in rehabilitation: “I think it’s important for family members to expect some recovery. It may not be full recovery, back to the way the person was before, but it is not a death sentence. I think we have to say there is definitely hope. If you made it through the acute phase, there is definitely hope.”
  The End of Medicare Outpatient Therapy CapsThe two-year budget deal, approved by the House and the Senate and signed into law in February, included provisions that expand access for telestroke and cardiac rehabilitation services, remove restrictions on Medicare outpatient therapy caps and help improve the health of patients with cardiovascular disease.
  Past caps on therapy have seriously limited treatment options for millions of Americans. As a result of the budget deal, Medicare patients will have access to medically necessary rehabilitation services without the $2,000 limit that was in place. Brennan cautioned that this repeal does not throw open the doors of rehab facilities for unlimited rehab for survivors. “Although the cap on Medicare therapy has been repealed, established Medicare guidelines are still in place,” she said. “This means there are still limitations to what Medicare will cover, from a medical necessity standpoint.”
  Patient Profile: CONNIE STAGNAROSeventeen years ago, when she was 38, Connie had a TIA while riding a bike in Woodstock, New York. When the EMTs examined her, they thought it was heat stroke, administered fluids and sent her on her way. After returning home to Manhattan the next day, her left side went limp while crossing the street, and she was taken by ambulance to a nearby hospital. Connie had had a stroke. She later transferred to Rusk Institute of Rehabilitation Medicine at New York University for inpatient therapy. “At that point, I could not move the left side of my body and had mild left side facial drooping,” she recalled. “Fortunately, there were no cognitive deficits, and I could speak clearly.”
  She describes inpatient therapy as “boot camp — in the best sense.” Before leaving inpatient therapy, she met with her primary rehab doctor and physical therapist; at that time, her deficits were left side weakness and lack of feeling in her left hand.
  After her discharge from “boot camp,” Connie visited Rusk once a week as an outpatient for a month. “The schedule was rigorous with both occupational and physical therapy, and the exercises focused on my deficits,” she said. “We also discussed how to manage my daily needs. For example, when I should use a cane and how to manage myself in crowds. I did think I would always need a cane, but my confidence grew as I returned to my daily routine. I eventually gave up the cane. My preferred one toward the end was a folding cane that I could keep in my bag just in case I needed one.”
  Her therapist emphasized exercises to boost her stability in crowds because her commute to work involved riding two buses, a subway and walking on crowded sidewalks. “She would gently push me as I walked to improve my balance,” Connie said. “She was particularly kind when I broke down and cried after feeling overwhelmed by my entire post-stroke experience.”
  Survivor Connie Stangaro with her furry friend
  
  Connie describes inpatient therapy as “boot camp — in the best sense.”After discharge from the outpatient program at Rusk, she continued therapy at home on a weekly basis. The exercises included strength exercises on a mat and walking/gait exercises.
  “Those sessions at home were helpful because they were in a nonclinical, real-world environment,” she said. “I lived on a cul-de-sac, so my therapist could safely have me walk outside my home, over ruts and imperfections.”
  Connie’s goal was to feel independent and reduce the anxiety she felt about her commute: “While the buses didn’t unnerve me much, any subway rides made me anxious because of the jostling crowds and the likely inability to sit. It did take me some time to be able to ride on a subway alone. I wanted to feel physical stability again.”
  Connie did return to her job as an archivist in a research library after five months: “I felt confident in my ability to navigate in public areas and often move boxes and files,” she said. Her deficits slowly lessened as she returned to her daily routine. “While I’m considered ‘cured,’ if I get too tired or I’m sick, I do feel mild weakness on my left side, particularly when I’m walking. Doctors never found a cause for my stroke. My paternal grandmother did suffer a stroke at the same age I did, so I most probably had some genetic disposition. I continue taking a blood thinner. The trauma I suffered is past, but my body remembers when I feel depleted emotionally or physically. My left side can feel the effects of any slight physical debilitation. For example, I was recently diagnosed with a problem with my proprioception (the sense that gives you orientation as you move) because of slight arthritis in my neck. My balance is slightly compromised, and my stroke side may feel weaker. But whatever indirect physical impediments I may face as a reminder of my stroke, I know from experience that the brain’s ability to adapt is a marvel!”
  Before Leaving the HospitalHere are some things to keep in mind as you are planning for discharge from the hospital:
• Not all types of facilities are available everywhere; so, depending on where you live, you may have lots of choices, few choices or no choice at all without travelling some distance.
• Insurance may limit what facilities are available, e.g. a specific facility may not be “in-network” on your health plan.
• If there are multiple options in your area, ask the healthcare team for a recommendation.
• Find out more about any recommended facility. Check it out on the Medicare or Commission on the Accreditation of Rehabilitation Facilities websites that share quality rating and accreditation information. Talk with staff of the facility and take a tour.
• Use these free American Stroke Association resources to help:
  • Making Rehabilitation Decisions guide— This 9-page guide helps shine light on what to expect and how to make the best decisions about your next recovery steps.
  • Stroke Rehab Planning List-This 2-page, quick reference will help you ask all the right questions as you make decisions about your stroke rehab.
• Visit the American Stroke Association website for more information and resources about stroke rehab and recovery.
  This information is provided as a resource to our readers. The tips, products or resources listed or linked to have not been reviewed or endorsed by the American Stroke Association.

Reference: 
​http://strokeconnection.strokeassociation.org/Summer-2018/What-to-Expect-from-Outpatient-Rehab/