Navigating Complex Neuro Rehabilitation: From Hospital to Home
This presentation examines the complex transition of neurological rehabilitation patients from acute hospital settings to home and community-based care. It outlines the continuum of neurorehabilitation services and highlights common barriers to successful discharge, including fragmented care coordination, limited access to specialized services, insurance constraints, caregiver burden, and environmental challenges. Emphasis is placed on the critical role of the case manager in navigating these barriers through interdisciplinary coordination, patient and caregiver education, and proactive discharge planning. Evidence-based strategies and practical tools—such as standardized handoff processes, caregiver readiness assessments, and therapy intensity bridging—are explored to reduce readmissions and improve functional outcomes. The presentation ultimately promotes a patient-centered, continuity-driven approach that supports safe transitions, maximizes independence, and enhances quality of life for individuals with neurological conditions.
Location: Andiamo Bloomfield; 6676 Telegraph Rd, Bloomfield Township, MI 48301
