Identifying Evidence

A. The following section highlights a research-based discharge and post-discharge strategy for Jean’s stroke and lack of mobility conditions. The discharge planning for the patient’s stroke condition includes referral to Agency for Integrated Care to help arrange for Jean’s essential services, in this case, rehabilitation program. Recommendation for physical environment modification and mobility equipment and organizing for post-discharge outpatient clinic appointments is also part of this phase’s plan. Stroke is a leading cause for the adults’ disability onset. Approximately 70 to 85% of the first stroke is characterized by hemiplegia, and only about 60% of the patients who require rehabilitation achieve functional independence in simple routine activities such as walking short distances or toileting (Ayala et al., 2015). Rehabilitation is essential for stroke patients and integrates organized multidisciplinary and support services to regain functional independence (Aadal et al., 2018). Outpatient rehabilitation will be advantageous for Jean to cut on the care costs as the patient is currently struggling financially.

II. Inpatient Assessment

A. Inpatient Client Needs Using a Strengths-Based Focus

Jean derives her strength from her faith as a devout Catholic, which gives her moral support and comfort. The patient has a great sense of humor and is a very organized woman, an elementary school teacher. Jean has a strong social circle, comprising of friends to interact with, and she also participates in a local garden club and is part of her neighborhood welcoming committee. Her children also visit her often. Combining these factors provides the patient with the much-needed support to cope with the psychological traumas caused by lack of mobility. The social circle and the patient’s sense of humor can help her manage the trauma due to the rape, which is a central psychological issue the client is facing currently. The trauma caused by the rape incident and the patient’s inability to walk impacts her psychological wellbeing. Reactions to trauma may include agitations and physical arousal or blunted affect, and the survivor pay shows reactive response even to an imaginary threat. However, having social support can help the patient to cope with the impacts.

B. Potential Complexities Could the Client Encounter during Her Inpatient Stay

The physical geographic environment of the care facility may not be conducive to the patient’s wheelchair use. This poses a barrier to the patient’s movements, which is an essential facet of physical therapy or causes dependence on the family members or caregiver for assistance. Lack of privacy in most rehabilitation facilities is another challenge that may re-traumatize the patient.

C. Ensuring the Client Is Not Re-Traumatized

            The family members providing support during the rehabilitation must be educated on the patient’s conditions, the intervening environmental factors, and potential implications of the same to assist Jean accordingly. Psychological and social support will be inseparable during the therapy to ensure that the patient does not burden the rehabilitation support groups. Stroke support groups can help enhance social support and awareness.

D. Strategies to Address the Client’s Inpatient Financial Needs

Jean’s financial needs’ best strategy is to assist her in applying for the “Social Security Administration (SSA).” The SAA is a U.S. government social insurance program for the retired people, disabled persons, and survivor benefits to offset some of the financial burdens due to catastrophic events such as stroke. Jean qualifies for the programs she is on retirement or without income.

III. The Interdisciplinary Team

A. An interdisciplinary team working is considered essential for providing effective care across the stroke pathway. The physiotherapist, clinical social worker, nurse, and occupational therapist are essential interdisciplinary team members. Each member of the team contributes specialized knowledge and intervention on behalf of the patient.

B. Role of Each Member in the Interdisciplinary Team

1. Improving Patient Care

The physiotherapist helps prevent tissue and joint injury and regain lost motor skills, hence helping the patient fully retain her mobility and independence. On the one hand, the occupation therapist considers the stroke patients in their environment, helping them regain and improve function in all the daily fundamental areas.

2. Improving Patient Outcomes

The clinical social worker is responsible for developing a cost-effective care plan for the patient. Clinical social workers focus on psychological assessments and interventions with their patients and their families, helping them adjust the care process and plan for discharge. Besides, the nurse also plays a significant role in developing a cost-effective care plan, acting as the multidisciplinary team coordinator (Miller et al. 2010). The nurse in this role facilitates the social worker and the physiotherapist’s work by providing them with valuable information and therapeutic reinforcement activities when the patient is on the nursing care unit (Aadal et al., 2018).

C. Strategies to Help the Jean Understand the Team and Outcomes of Post-Discharge Plan

            The strategy to enhance collaboration between the patient, the family, and the multidisciplinary team during discharge planning. This will include explaining to the patient the essential treatments needed now and, in the future, the follow-up appointments, and the type of medications necessary.

IV. Follow-Up Care Plan

A. The Basic Post-Discharge Client Needs

Jean’s basic post-discharge needs include assistance with mobility, such as helping the patient get on the wheelchair, and other personal help such as bathing and dressing before the patient recovers fully. Coordination of healthcare needs, including medications and rehabilitation and doctor appointments, is also necessary for Jean’s condition. Helping the patient improve her ability to function and manage her insurance coverage and finance will also be necessary.

B. Strategies to Arrange Provision of Services to the Client

Collaboration with and training family and primary caregivers will be an essential strategy in ensuring that the client receives all the essential services without fail and reduces complications that may lead to readmission. Also, doing a follow-up by a clinical social worker is equally vital in this case.  

C. Strategies to Address the Client’s Post-Discharge Financial Needs

Educating the patient and the family on the financial assistance available for Jean Social Security Administration (SSA) insurance coverage programs and essential information and procedures required to access such services will be essential for the case of Jean. 7

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V. Conclusion

The challenge to navigate both available resources for inpatient and discharge client needs as presented in this care plan may lead to re-traumatization, worsening of the patient’s health condition, and reinitiating readmission. Facilitating inpatient care services such as medication and outpatient services, including improving patient mobility and financial needs, helps enhance psychological wellbeing and the patient’s full recovery in the long-term. Jean will have a quick recovery and regain her function if everything is well taken care of according to the care plan.

VI. Academic Reflection

Stroke is the primary cause of disability and mortality in the United States. About 800,000 American adults suffer a stroke annually (Ayala et al., 2018).  Presently nearly six million survivors live in the U.S. Participation in stroke rehabilitation, which happens in diverse settings, including in-hospital, outpatient, and post-acute care settings, have been established to improve patient’s functional outcomes and overall quality of life (Ayala et al., 2018). Outpatient rehabilitation is cost-effective and helps extend medical care to underserved populations (Ayala et al., 2018). Access to social insurance covers in the U.S., including Security Administration (SSA), can help stroke patients such as Jean manage their care bills.


Aadal, L., Angel, S., Langhorn, L., Pedersen, B. B., & Dreyer, P. (2018). Nursing roles and functions addressing relatives during in‐hospital rehabilitation following stroke. Care needs and involvement. Scandinavian journal of caring sciences32(2), 871-879.

Ayala, C., Fang, J., Luncheon, C., King, S. C., Chang, T., Ritchey, M., & Loustalot, F. (2018). Use of outpatient rehabilitation among adult stroke survivors—20 states and the District of Columbia, 2013, and four states, 2015. Morbidity and Mortality Weekly Report67(20), 575.

Miller, E. L., Murray, L., Richards, L., Zorowitz, R. D., Bakas, T., Clark, P., & Billinger, S. A. (2010). Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke41(10), 2402-2448.