Continuum of Care Lecture

Question 1

What is the primary goal of evaluation in acute care settings for neuro rehab?

Answer 1

To determine the patient’s safety for discharge home or their need for further rehabilitation care.

Question 2

What are the six levels of Rehab for Discharge Recommendations?

Answer 2

1. Acute Rehab
2. Acute Rehab w/ slow to recover neuro program
3. LTAC
4. sub-acute (SNF)
5. home w/ or w/o services
6. outpatient

Question 3

What are the key differences in evaluation goals between acute rehab and homecare settings?

Answer 3

Acute Rehab: Focus on functional independence and progressing to the next care stage.

Homecare: Ensure safe home accessibility and determine the need for ongoing therapy

Question 4

What are examples of appropriate short-term and long-term goals for neuro rehab?

Answer 4

Short-term Goals: Bed mobility, transfer assistance, improving static sitting balance.

Long-term Goals: Ambulating without assistive devices, living independently, returning to work

Question 5

How do goal-setting priorities differ across acute care, SNF, and outpatient settings?

Answer 5

Acute Care: Discharge planning and safety.

SNF: Intermediate goals to restore mobility and ADL independence.

Outpatient: Long-term goals like community mobility and dynamic balance improvement.

Question 6

What adjustments should be made if a patient does not meet their rehab goals?

Answer 6

Reassess barriers to progress (e.g., illness, motivation).

Adjust interventions and set more realistic goals if needed.

Engage facilitators like family support or increased patient motivation.

Question 7

What are the key considerations when recommending a discharge location for a neuro rehab patient?

Answer 7

• Medical stability.
• Family/community support.
• Need for continued medical and rehab services.
• Patient’s long-term goals and prognosis.

Question 8

When should discharge planning begin, and what should it involve?

Answer 8

Begin at the initial evaluation or chart review.
Involve shared decision-making with the medical team, patient, family, and rehab team.

Question 9

How does prognosis influence the neuro rehab plan of care?

Answer 9

Acute Stroke: Most recovery occurs in the first 3 months, but improvements can continue for years.

Progressive Diseases: Focus on maintaining function and quality of life.

Question 10

What are some factors that should be considered during plan-of-care adjustments?

Answer 10

Were the goals realistic and achievable?

Was the patient sufficiently engaged and motivated?

Did unforeseen events (e.g., illness) hinder progress?

Question 11

What are examples of discharge options based on a patient’s needs in neuro rehab?

Answer 11

Acute Rehab: Intensive therapy for functional improvement.

SNF/Subacute: Slower recovery or lower therapy intensity.

Homecare: Safe home navigation with support.

Outpatient Rehab: Advanced mobility and reintegration goals.

Question 12

How does length of stay differ between an acute hospital, acute rehab, SNF, homecare, and outpatient?

Answer 12

• Acute Hospital = days
• Acute Rehab = weeks
• SNF = weeks
• Homecare = weeks to months
• Outpatient = months

Question 13

Overall goals for Parkinson’s?

Answer 13

Improvement on function
Establishing regular exercise program
Maintaining function if disease is more progressed
Preventing secondary sequela, especially as disease progresses

Question 14

Overall goals for ALS?

Answer 14

Improvement in function or endurance, not strength
Maintain function as disease progresses
Preventing secondary sequela, especially as disease progresses

Question 15

Overall goals for GBS?

Answer 15

Functional mobility focused, minimizing secondary consequences before and during Nadir
After Nadir, focus on improving function

Question 16

Overall goals for Stroke?

Answer 16

Focus on improving function throughout rehab

Question 17

What precautions should be taken during strengthening exercises for GBS patients?

Answer 17

strict avoidance of antigravity strain on the muscles until they are at least a 3/5
Progress exercises very slowly, with frequent rest periods.
Stop activity at the first sign of fatigue or muscle ache.

Question 18

What are examples of PT goals for ALS in early vs. late stages?

Answer 18

Early Stage: Strengthen unaffected muscles and maintain mobility.
Late Stage: Optimize comfort, prevent contractures, and improve quality of life

Question 19

What is the focus of GBS treatment during the progression phase?

Answer 19

Prevent complications such as contractures and pressure injuries.
Monitor respiratory function closely.
Use gentle PROM and proper positioning to maintain joint mobility.
Avoid overexertion to reduce strain on affected muscles

Question 20

What is the focus of GBS treatment during the nadir phase?

Answer 20

Provide supportive care and prevent secondary complications.
Maintain joint integrity through positioning and gentle interventions.
Avoid active exercises until muscles are at least 3/5 strength

Question 21

What is the focus of GBS treatment during the recovery phase?

Answer 21

Gradually introduce active exercises with frequent rest periods.
Monitor for signs of fatigue or muscle overexertion.
Emphasize functional mobility training and energy conservation strategies

Question 22

What is the stroke prognosis?

Answer 22

Recovery from stroke is fastest in the first few weeks after onset, with the most measurable neurologic recovery, approximately 90%, in the first 3 months.