ModuleDraft

Internist module: Rehab referrals and DME after stroke (PT/OT/SLP, PM&R, home health) — outpatient playbook

Outpatient playbook for internists to screen rehab needs after stroke and place high-signal PT/OT/SLP/PM&R/home health referrals, document DME/home safety needs, and close the loop (placed → scheduled → started → reassess).

ClinicianClinicianIntermediate25 minClinical (pro)

Educational only

Educational only — referral pathways and coverage rules vary; coordinate with rehab teams and case management.

Get help now

For acute functional decline or new neuro deficits, send for emergent evaluation.

Key takeaways

  • Identify common outpatient rehab gaps (PT/OT/SLP) after discharge
  • Standardize referral documentation to improve access and reduce delays
  • Screen for DME/home safety needs and caregiver training

Rehab needs screen

  • Mobility
  • ADLs
  • Communication/swallow
  • Cognition

Referral map

  • PT
  • OT
  • SLP
  • PM&R
  • Home health

DME

  • Walker/wheelchair
  • AFO
  • Shower safety

Practice check

What you’ll practice

These questions are untimed. After you answer all of them, you’ll see your score and a clear next lesson or reference step.

0 of 2 answered

Question 1

1. Loop closure on rehab referrals (placed/scheduled/started) is a high-yield outpatient task.

Question 2

2. A common missed rehab domain is…

References

  1. Tier 1
    NICE NG236 Stroke rehabilitation in adults (2023)
  2. Tier 1
    AHA/ASA 2016 Stroke Rehabilitation & Recovery Guideline