The early weeks at home are the fragile ones
Gains are held or lost in the weeks after discharge, and the risks are practical rather than clinical.
The clinical work ends at discharge; the outcome does not. Gains made in an intensive programme can be lost in the weeks after going home — and when they are, it is rarely for medical reasons.
What goes wrong
The home programme stops because nobody is checking. Helpful family members do everything the patient can nearly do, and the ability quietly disappears. The environment defeats the plan — a bathroom that cannot be entered independently undoes weeks of transfer training.
None of these is a relapse. All of them are reversible, and all of them are easier to prevent than to fix.
Knowing when not to help
A person helped with everything they can nearly do stops being able to do it. Knowing where that line sits for a specific patient is taught during the stay and is one of the more difficult things a companion learns.
The line moves as the patient improves, which is part of what the follow-up reviews are for.
Set the checkpoints before you leave
A date for the first review, a named person to contact, and a written rule for what counts as a reason to make contact earlier.
Vague availability is not a follow-up plan. A scheduled appointment is.
Topic
More in Returning home and follow-up
- What you should leave with at dischargeThe documents that let a clinician at home continue from a known point rather than starting again.
- Remote follow-up: what it can and cannot replaceScheduled video reviews that adjust the home programme — useful for progression and technique, not a substitute for hands-on therapy.
