Can a stroke patient with an immobile left arm be safely discharged home?

Discharge Safety for Stroke Patients with Immobile Upper Extremity

A stroke patient with an immobile left arm should not be discharged directly home without a comprehensive assessment of functional mobility, fall risk, caregiver capacity, and home safety—and most patients with this degree of impairment require either inpatient rehabilitation or skilled nursing facility placement before home discharge. 1

Critical Assessment Before Any Discharge Decision

The presence of an immobile upper extremity indicates significant functional impairment that creates multiple safety risks requiring structured evaluation:

• Functional mobility must be formally assessed including activities of daily living, communication abilities, and the patient's ability to perform transfers, ambulation, and self-care tasks 1
• Fall risk is dramatically elevated in stroke patients with hemiparesis, with 22-48% experiencing at least one fall during hospitalization and up to 73% falling within the first year after stroke 1
• Bilateral lower extremity function determines discharge feasibility more than arm function alone—patients who can ambulate safely with assistive devices and have adequate leg strength may be candidates for home discharge with services, while those with bilateral weakness or inability to transfer safely require facility-based care 1, 2

Determining the Appropriate Discharge Destination

The discharge destination must be based on residual neurological deficits, cognitive status, swallowing ability, medical comorbidities, level of family/caregiver support, and the caregiver's capacity to meet care needs 1:

Inpatient Rehabilitation Facility (IRF) Criteria

• Patient needs close medical supervision and can participate in at least 3 hours of therapy per day, 5 days per week 1
• Patient has rehabilitation potential and is expected to return to community living 1
• This is the optimal setting for patients with moderate to severe deficits who have endurance for intensive therapy 1

Skilled Nursing Facility (SNF) Criteria

• Patient needs skilled nursing care but cannot tolerate 3 hours of daily therapy 1
• Patient can participate in therapy for less than 3 hours per day up to 5 days per week to improve functional ability 1
• This is appropriate for patients who are medically complex or have limited therapy tolerance 1

Home with Home Health Services Criteria

• Patient must be able to perform or direct basic self-care with caregiver assistance 1
• A dedicated caregiver must be available and trained in positioning, transfers, shoulder care, and prevention of complications 1
• Home environment must be assessed for safety with modifications completed before discharge 1
• Patient must be able to transfer safely with assistance and have minimal fall risk 1, 2

Mandatory Pre-Discharge Requirements for Home Discharge

If home discharge is being considered despite the immobile arm, these elements are non-negotiable 1:

• Home visit by occupational therapist to evaluate the environment, determine safety needs, identify required modifications, and assess equipment needs 1
• Caregiver training must be completed including communication strategies, positioning and handling techniques, transfer training, shoulder care (positioning the hemiplegic shoulder in maximum external rotation for 30 minutes daily), and how to promote independence within the patient's limitations 1, 2
• Fall prevention measures including removal of clutter, adequate lighting, properly fitted non-skid footwear, and assistive devices for all mobility 2, 3
• Pressure injury prevention education with repositioning every 2 hours and skin checks on the affected side 1, 2, 3
• Venous thromboembolism prevention through early mobilization and potentially continued pharmacological prophylaxis 1, 2, 3

Complications That Make Home Discharge Unsafe

The following complications associated with immobility make direct home discharge inappropriate without facility-based rehabilitation first 1, 2:

• Inability to perform transfers safely even with caregiver assistance—this creates unacceptable fall and injury risk 1, 2
• Dysphagia or aspiration risk requiring modified diet or feeding assistance, as aspiration pneumonia increases mortality 7-fold 2
• Cognitive impairment or impaired safety awareness that prevents the patient from calling for help or following precautions 1
• Inadequate caregiver support—if the family cannot provide 24-hour supervision and physical assistance, home discharge will fail 1
• Urinary or bowel incontinence requiring catheter management or extensive toileting assistance 2

Early Supported Discharge Programs as a Bridge

For patients with mild to moderate disability (modified Rankin Scale ≤3), early supported discharge programs allow transition home with intensive home-based rehabilitation services 1:

• These programs provide rehabilitation therapy at home with intensity and expertise similar to inpatient rehabilitation 1
• The key requirement is that the same interprofessional team that treated the patient in hospital continues care in the community—handoff models show less benefit 1
• Early supported discharge reduces hospital time and increases likelihood of independent community living compared to prolonged inpatient rehabilitation 1
• This option requires the patient to have adequate caregiver support and a safe home environment 1

Common Pitfalls to Avoid

• Discharging based solely on National Institutes of Health Stroke Scale score—patients scoring zero may still have significant motor deficits, truncal ataxia, or cognitive impairments that create safety risks 1
• Failing to assess caregiver capacity realistically—family members often overestimate their ability to provide the required level of care, leading to readmission 1
• Inadequate assessment of the home environment—stairs, bathroom accessibility, and narrow doorways may make home discharge impossible without modifications 1
• Discharging without establishing follow-up rehabilitation services—stroke survivors need ongoing assessment throughout their lifetime to prevent readmission and maintain function 1
• Underestimating fall risk—falls are independently associated with loss of function even after adjustment for stroke severity, and hip fractures occurring within 7 days post-stroke are associated with poor prognosis 1, 3

The Bottom Line

An immobile left arm represents significant functional impairment that typically requires facility-based rehabilitation before safe home discharge. The decision must be based on comprehensive assessment of bilateral mobility, cognitive function, caregiver capacity, and home safety—not on the arm function alone 1. Most patients with complete upper extremity paralysis will benefit from inpatient rehabilitation or skilled nursing facility placement to maximize recovery and ensure safe community reintegration 1.