Three Hours a Day, and Nobody at Home
Mr. A is 78 and on day 6 of an admission for a left middle cerebral artery stroke; NIHSS is 8. He has right hemiparesis (arm 2/5, leg 3/5), moderate Broca's aphasia, follows one-step commands, has no neglect, and is medically stable on aspirin and a statin. He lives on the second floor of a walk-up with his wife, 74, who uses a walker, does not drive, and has never provided care for him. When the team says the word 'SNF,' he repeatedly says 'home' and becomes agitated; when asked to choose between two unfamiliar options, he nods to both. He has Original Medicare with no supplement. The physiatrist recommends an inpatient rehabilitation facility and asks the case manager to 'make it happen by Friday.'
1. Apply the criteria for inpatient rehabilitation and recommend a setting.
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Three questions decide it: does he need and can he tolerate intensive therapy, does he need 24-hour medical supervision, and where can he realistically go?
IRF criteria. A physician-directed program with 24-hour nursing, a multidisciplinary team, and typically three hours of therapy five days a week; the patient must need that intensity and be able to participate. Stroke is one of the qualifying conditions for the facility-level 60% rule - but that rule is a compliance obligation on the facility, not an individual eligibility criterion, and it is regularly misused in both directions.
Does he meet them? Medically stable, dense hemiparesis, needs PT, OT, and speech. He is a plausible IRF candidate. But the aphasia and the nodding make both his ability to participate and his discharge destination uncertain, and IRFs screen for both. Three hours a day works only if the therapy is productive, not merely scheduled.
SNF alternative. Skilled nursing with subacute rehab, usually less therapy per day, with 24-hour nursing - better if endurance is poor or medical monitoring is needed.
Recommendation. Ask PT and SLP to document tolerance for two consecutive hours of therapy and his ability to follow a program, and request a formal IRF preadmission screen. If he can participate, IRF with a planned step-down is strongest; if not, SNF now with a re-screen in two weeks. What is not defensible is 'make it happen by Friday' before those two questions are answered.
2. How should the team establish Mr. A's own preference given his aphasia?
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Aphasia is a language disorder, not a thinking disorder. Assuming incapacity because he nods is the error to avoid.
Bring in SLP. Request a communication assessment and a recommendation on supports: yes/no cards, written choices, gesture, a trained communication partner, extra response time.
Ask in a form he can answer. Not 'IRF or SNF,' but 'Do you want to work hard on walking every day - yes or no?' Pair the words with pictures. Ask the same question two ways on two occasions and check for consistency.
Confirm comprehension. Teach-back: 'Show me where you would go after the hospital.'
Separate capacity from communication. Capacity is decision-specific and clinical. He may be able to choose a discharge destination while being unable to manage finances. The physician and SLP should document how he communicated, not only what he chose.
Interpret 'home' carefully. It may mean the place, it may mean 'not a nursing home,' it may mean 'with my wife.' Explore with his wife present, but let him answer first.
Revisit. Language improves. A preference expressed on day 6 may differ on day 20, so re-check before discharge rather than treating one conversation as final.
3. Is discharge home safe, and what does the case manager need to arrange or document?
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Home may be feasible, but not on the current facts, and 'he said home' is not a plan.
The problems. A second-floor walk-up; a wife with her own mobility limitation who has never provided this care; no driver in the household; daytime coverage unknown; and dense hemiparesis means transfers, toileting, and bathing all require help.
What to arrange. An OT home evaluation before discharge rather than after; a ramp or stair glide - noting that Medicare does not pay for home modifications, so identify who does (state waiver, VA if eligible, community grants); durable medical equipment; home health PT, OT, and nursing; transportation to outpatient therapy; a personal emergency response system; and a written daily schedule naming who is present at each point in the day.
What to say. Name the risk plainly without catastrophizing, and offer the alternative: a short SNF stay that lets the home be prepared and the wife be trained, with a target home date.
What to document. That he was given the options and the risks, what he chose, how he communicated the choice, what was arranged, and what remains unresolved. If he chooses home with thinner supports than you would like, that is his right - record it as an informed choice, not as an error, and schedule early follow-up so a failing plan is caught in days rather than at the next admission.