Algorithm A Algorithm B Algorithm C

Community Based Rehabilitation
Continue from Algorithm B
Patient post-stroke ready for community living [T]
Does patient need community-based rehabilitation services? [V] Box 26 yes to box 27
Box 26 no to box 33 Determine optimal environment for community based rehabilitation [W] Assessment of Discharge Environment: Functional needs, motivation and preferences, Intensity of tolerable treatment in equipment and duration, availability and eligibilty, transportation, and home assessment for safety
Educate patient/family. Reach shared decision regarding rehabilitation program and treatment plan. Continue secondary prevention [R]
Continue rehabilitation intervention
Did patient achieve optimal function or reach a plateau? Box 30 yes to box 31
Discharge patient to prior home/community setting. Arrange for primary care follow-up [N] Reassess periodically. Return to box 29 Discharege patient to prior home/community setting. Arrange for primary care follow-up [N]