Diane M. Chappuis, MD, OT
Medical Director of Stroke Rehabilitation
Courage Kenny Rehabilitation Institute

Nancy Flinn, PhD, OTR/L
Senior Scientific Advisor
Courage Kenny Rehabilitation Institute

Jill Henly, MSW
Manager, Care Mangement
Courage Kenny Rehabilitation Institue, part of Allina Health

Stacy Shamblott, CTRS
SHARE Program Coordinator
Courage Kenny Rehabilitation Institute

Kara Patterson, DPT
Physical Therapist
Baylor Institute for Rehabilitation

Marlene Vega

Marlene Vega, PsyD
Assistant Professor
UT Southwestern Medical Center

Optimizing Transitions of Care for Stroke Rehabilitation, From Day One to Community Reintegration IC26


DAY Friday 14 April 2019

TIME 9:00 AM – 1:00 PM

FORMAT 4-hours instructional course, Demonstration

ROOM LOCATION  to be determined

TOPIC AREAS Stroke, Clinical Practice

CAREER LEVEL  Intermediate



Occupational Therapists, Physical Therapists, Speech Language Pathologists, Medical Doctors, Rehab Nursing, Therapy or Nursing Managers, Care Coordinators, Program Managers, Psychologists


Course Description

There have been significant advancements in the medical treatment of acute stroke in the past 15 years, but the care of stroke survivors following acute medical stabilization is paramount to their ultimate outcome. Patient outcomes have many domains, such as motor, language or cognitive outcomes. However, we are paying increased attention to psychological health, return to life and family roles, return to community, fitness and avocational pursuits. Our additional challenge is to provide these services in a patient and family centered way, which is efficient but low in cost, and integrates secondary stroke prevention strategies.
The use of a “high touch” strategy when dealing with patients and families will assist them in navigating the confusing and complex path of post-acute care services. At the same time, taking advantage of “high tech” options for tracking and monitoring those under our care and providing them with the right care at the right time is an ideal we would like to strive for.
We will present strategies for improving transitions of care in each arena, including the acute hospital stay, post hospital rehabilitation setting, home care, outpatient therapy and return to community.  We will include emphasis on integrating secondary stroke prevention through sports, health, activity, recreation and exercise.
The use of care coordination in health care has increased greatly over the past five years.  However, it is fairly unique to integrate rehabilitation care coordinators in the acute hospital setting and for at least 9-12 months post stroke. We know that taking good advantage of the first few months of rehabilitation efforts are especially fruitful in terms of neuroplasticity and patient outcome. If the first connection to rehabilitation services post acute hospital stay is delayed or lost, this can potentially reduce chances of an excellent outcome.  The importance of making this first connection and coordinating with other services such as Neurology, Neurosurgery and Neurointerventional Radiology will be discussed.   A baseline status of non-care coordinated stroke survivors will be compared to the status of 4 years of those who did have access to care coordination services.  Differences in emergency department visits, therapy and physician visits, mortality and readmission to hospital will be presented.
We will also discuss proactive discharge preparedness to improve rate of community discharges, improve generalization of acquired skills from the acute care to community setting, and address barriers to successful community reintegration through early caregiver activation and caregiver empowerment. To illustrate this, implementation of a three pronged transdisciplinary approach to early activation is presented. Component one is the “Functional Program” which aims to improve continuity and repetition of functional mobility with family and staff and enhance understanding of post-stroke motor recovery. Component two includes “My Personal Health Goal” which promotes patient-centered care and patient engagement in development of exercises to promote salience. Component three includes the “Get Home Program” which focuses on family education, repetition of exercises and training, and hands on discharge preparedness. Family training was initiated within 10 days of admission to inpatient acute rehabilitation and continued weekly. Training was functionally patient-specific and exercises were given for the weekend. A gap analysis was completed to establish better communication and a more transdisciplinary approach between nursing and therapist. Solutions for improving health literacy of stroke survivors and caregivers will be explored.



Upon completion of the course, participants should be able to:

  1. Discuss an innovative transdisciplinary process for maximizing preparedness from inpatient discharge.
  2.  Improve patient/client transitions to post acute care settings
  3. Identify community reintegration strategies

CME/CEUS 4 Hours

ACRM Training Institute registration includes CME/CEUs for the following disciplines:

  • Case Managers (CCMC)
  • Disability Management Specialists (CDMS)
  • Healthcare Executives (ACHE)
  • Nurses (ANCC)
  • Occupational Therapists (AOTA)
  • Physical Therapists (FSBPT-24 states)
  • Physicians (ACCME-CME)
  • Psychologists (APA Division 22)
  • Rehabilitation Counselors (CRCC)
  • Social Workers (NASW)
  • Speech Therapists (ASHA)


4 hours of live instruction, continuing education credit processing, access to presentation slides (if provided by presenters), NON-ACRM members receive introductory 6- month membership.



Early Bird rate $49 for members and $99 for non-members      and that includes CME / CEU processing. See the rate tables here.

We encourage you to register early      before tickets are gone. Don’t say we didn’t warn you.

Limited space available


The secret sauce for your career


Discounted for ACRM members, the ACRM Spring Meeting offers instructional courses with continuing education credits in your choice of up to 11 disciplines.

Jump in, get involved, meet and work with ACRM members face-to-face in a casual setting. This event is all about getting research into practice in a supercharged atmosphere and a friendly, collaborative, and inspiring environment.


28+ instructional courses. Scroll + see the agenda…

The ACRM Spring Meeting is a venue for face-to-face collaborating of many interdisciplinary ACRM community groups and committees — the heart of ACRM. Come find your tribe and become a member of the vibrant ACRM community.


Ridiculously inexpensive? Yep. That’s because we believe in getting the research to practice ASAP. And we think that having a low-cost to attend is a good way to do that.

Early Bird rates are as low as $49 for members and $99 for non-members — and that includes CME / CEU processing. Are you kidding me?!? Nope. See the rate tables here.

We encourage you to register early — before tickets are gone. Don’t say we didn’t warn you.


You’re our people

ACRM attendees are all kinds of rehabilitation professionals — from researchers to clinicians (including
doctors, nurses, PT assistants, hospital administrators to name just a few) to consumers, family, caregivers, and
more. Everyone is invited and warmly welcomed at ACRM.

They span a wide spectrum of experience from students to well-seasoned pros and hail from the largest
rehabilitation institutions and universities to one-person solopreneurs.
Attendees at previous ACRM events include designers, art directors, and production staff from hundreds of
institutions, companies, and universities from all around the world, including:



This place is beautiful. The Hilton Chicago is the optimum headquarters with superb onsite amenities + easy access to the best of Chicago.

  • SAVE TIME — staying right in the ACTION the ultimate venue for efficient collaboration
  • SAVE MONEY — book your room through ACRM and SAVE
  • CONVENIENCE — you are only an elevator ride away from courses and meeting and located right on the famed Michigan avenue — smack in the middle of city hotspots — Grant Park, museums, Navy Pier, and more
  • HEALTH CLUB — on the 8th floor, it’s the largest hotel gym in Chicago with indoor pool and hot tub an indoor running track, strength training and cardio equipment, Synergy 360, and sundeck with views of the Chicago skyline.
  • HHONORS Club — join the Hilton Honors through the ACRM Fast Track to GOLD program and get EXTRA points and all the cool member benefits including digital check-in.
  • Get the HHONORS APP — TIP: It’s really VERY handy

BOOK NOW to enjoy the SAVINGS and CONVENIENCE of staying on-site at the headquarters hotel.

Or book Hilton by phone: +1.877.865.5320
with Booking Code: ACR to ensure the lowest rates
(Code: ACT for Government booking)

Space is limited. So lock in your seat and REGISTER TODAY >>