Physical medicine and rehabilitation clinics as transitional care hubs after stroke

The transition from hospital-based care to community living is a vulnerable period for stroke survivors and caregivers. During this period, patients often experience evolving medical, functional, psychosocial, and social needs while navigating fragmented systems of care. Although guidelines emphasize timely post-discharge follow-up, coordinated discharge planning, rehabilitation continuity, and linkage to primary care and community resources, there remains no consistently implemented model for delivering transitional care after stroke. Outpatient Physical Medicine and Rehabilitation (PM&R) clinics are well positioned to address this gap because physiatrists routinely manage post-stroke disability, functional recovery, secondary complications, therapy coordination, equipment needs, caregiver concerns, and barriers to community reintegration. This Perspective proposes a PM&R-based bridge clinic model for selected stroke survivors discharged home from acute care or inpatient rehabilitation settings, particularly those without established primary care or with barriers to timely outpatient follow-up. In this model, a small interdisciplinary core team, including a rehabilitation physician, advanced practice provider, and social worker or care coordinator, provides time-limited post-discharge follow-up focused on medical, mental health, and functional stabilization, medication reconciliation, rehabilitation planning, durable medical equipment needs, social drivers of health, caregiver support, and primary care linkage. By embedding transitional care within existing outpatient rehabilitation infrastructure, PM&R-based bridge clinics may offer a practical and scalable approach to strengthening continuity across the post-stroke care continuum.