The 5 Stages of Post-Stroke Care: Each is Critical to Recovery

Learning about the stages of post-stroke care is important so that survivors and their loved ones can manage and optimize rehabilitation, and therefore attain the best possible quality of life.

Almost 800,000 people suffer a stroke each year in the United States. Strokes can occur at any age, and nearly 25% of strokes occur in people under 65. Regardless of your age, understanding the stages of recovery can help with your navigation through it.

Understanding the Stages of Post-Stroke Care

Stroke recovery depends on many factors: where in the brain the stroke occurred, how much of the brain was impacted, caregiver support, the quantity and quality of rehabilitation, and how healthy the survivor was before the stroke. 

Each stage of medical care is designed to help survivors regain independence and return home as soon as possible. However, the process can be slow and uncertain. Support and encouragement from friends and family, as well as the survivor’s own attitude, are critical to making progress.

As soon as possible after stroke, caregivers and patients should learn the ins and outs of insurance coverage to clarify what medical and rehabilitation services are available, determine the length of coverage provided, and what out-of-pocket expenses can be expected.

Everybody is different: Not all people go through the “5 stages” progression in the same way. It depends on many factors, including the severity of the stroke, what part of the brain is affected, their age, and other factors. Some may not be able to return home. On the other hand, someone may have a minor stroke and only require outpatient services. This article describes a common progression through stages of care, but each person will experience a unique progression based on their circumstances. Your medical provider will explain your unique needs and therapy program.

Five Stages of Post-Stroke Care

Stage 1. The Hospital / Acute Care Stage: Critical time after stroke

A stroke is a medical emergency and those suffering a stroke should be taken to a hospital immediately. The critical time after stroke is to get to the hospital within 3 hours of noticing stroke symptoms so that the clot-busting drug tPA can be administered if warranted. For this treatment to be considered, there must be enough time to determine, via a CT scan or an MRI, whether the stroke is ischemic (caused by a clot) or hemorrhagic (caused by a bleed).

The duration of stay in the hospital can range from a few days to even a few months in rare cases. Factors that influence duration include the need for surgery, the cause of stroke, and what therapy is needed. Survivors of stroke and family members may find the hospital experience confusing, so be sure to ask as many questions as are needed of hospital staff. They are there to help. Before acute care ends, patients and family work with hospital staff to decide what the next step will be. For many patients, the next step is to continue rehabilitation – usually either inpatient care, or at a skilled nursing facility.

Stage 2. Inpatient Rehabilitation / Skilled Nursing Facility (SNF)

An inpatient rehabilitation facility or hospital is a short-term living facility and is generally geared for patients who can participate in a minimum of three hours of therapy a day, benefit from more than one type of therapy (like physical therapy, occupational therapy, and speech therapy), and are planning to reintegrate into community living. An organized team of specially trained professionals provides intensive inpatient therapy.

A skilled nursing facility (SNF) is intended for survivors of stroke who require daily, but less intensive therapy. Nursing facility programs are very different from each other, so it is important to get specific information about each one. Some provide a complete range of rehabilitation services; others provide only limited services. There may be different areas of the skilled nursing facility geared towards either short-term or long-term stays.

The first three months after stroke are often when rapid healing occurs. Therefore, patients and caregivers should be trying to optimize rehabilitation in this stage, so ask lots of questions about what’s the best possible care.

During this stage, rehabilitation goals will be set in concert with the patient, family, and rehabilitation program staff. It’s important they be realistic, as if goals are too high, the patient will not be able to reach them, or if they’re too low, the patient may not get all the services that would help. And if they don’t match the patient’s interests, the patient may not want to work at them.

Patients are usually discharged from inpatient care soon after their initial goals have been reached. The staff will engage the patient and family in “discharge planning” beforehand to help maintain the benefits of rehabilitation after discharge from the in-patient program. Some things discussed during discharge planning include:

• Making sure the survivor has a safe place to live.
• Deciding what care, assistance, or special equipment is needed.
• Arranging for further rehabilitation services, if needed (home care or outpatient care).
• Determining which caregivers will provide daily care and assistance at home.

Stage 3. At-Home Health Care

Often after discharge from inpatient rehabilitation, survivors of stroke will receive at-home healthcare. Individuals may work with one or multiple disciplines in their home, which could include speech-language therapy, occupational therapy, physical therapy, and nursing.

In this stage, clinicians will visit the home several times a week and pick up where inpatient rehabilitation left off.  One benefit of home care is that clinician can work on goals in the person’s home environment with the goal of increasing independence in daily activities. After this course of therapy, the clinician will determine if this person should be discharged from therapy services, or if more therapy is needed, they may be referred to outpatient rehabilitation.

Stage 4. Outpatient Rehabilitation 

After discharge from the hospital, SNF, or home care services, survivors may receive outpatient care. 

Outpatient programs allow patients to live at home and get a range of services by visiting a hospital outpatient department, outpatient rehabilitation clinic, or day hospital program. At these clinics, you’ll likely visit once or twice a week and work with speech, occupational and /or physical therapists to achieve your recovery goals.

At this stage, caregivers become even more important to recovery. Caregivers are often family members such as a spouse, adult son or daughter, or professional home health aides. Caregivers need to be able to:

• Make sure the patient takes prescribed medicines and follows suggestions about diet, exercise, and rest.
• Encourage and help the patient to practice skills learned in rehabilitation.
• Help with personal care, if the patient cannot manage alone.
• Arrange for needed community services, and drive back and forth to outpatient services.
• Advocate for the survivor.

Caregiving is a long-term, evolving process and can be frustrating especially at first. However, as a caregiver, there are things you can do to ease the transition.

As the individual gets close to discharge from therapy, the survivor and family members may want to explore other resources and organizations available to maintain or continue to work on the skills targeted in rehabilitation. Local university clinics may have also have individual or group therapy.

Stay motivated throughout the recovery process. Consistent practice is essential in recovery. Sometimes the move to this stage of care coincides with a slowdown in brain recovery progress, called a “plateau.” Don’t mistake a slowdown in progress as a sign that recovery is stopping . Science has shown recovery only stops when you stop. Read our article on recovery plateaus to find out why and how to keep motivated and going strong.

Stage 5. After Discharge

Science has shown that survivors can continue to get better even years after stroke. You can continue to make progress at home by continuing therapy activities on your own. Ask your speech-language pathologist about any low-cost or free therapy services in your community. Universities offering speech-language pathology training programs may have clinics that provide individual or group therapy. There may also be research programs that provide free or low-cost therapy for individuals who qualify for participation in studies.

The risk of having a stroke is higher for people who have had one already. To reduce that risk,  your doctor will typically ask you to follow advice on things like healthy diet, exercise, alcohol and smoking, and to monitor your blood pressure regularly. And if you notice a change in your recovery progression, tell your doctor, as it can be a sign of a problem.

In addition, mobile therapy apps like Constant Therapy can provide a continuous link between all care stages, from inpatient care to post-discharge. The reporting feature within Constant Therapy maintains a therapy progress link from the earliest stages of a patient’s recovery, as well as continuing to customize the thinking and speech exercises so that patients are getting exactly what they need at the right time, to meet their recovery goals.

Advocacy is Key to All Stages of Care

You’ll notice that self-advocacy is a common theme to each of the stages of care. The more informed questions you and your caregivers can ask along the way, the better your recovery outcomes will be.

Additional Stroke Resources

• National Stroke Association
• American Stroke Association
• Centers for Disease Control