Case 3: 49-year-old female		General view four months after onset of right capsular hemorrhage. Problems and responses in the first 16 weeks after admission to a convalescent rehabilitation ward.
① Clinical features		Hypertension noted 1 year ago but no medication, sudden left hemiplegia 4 months ago, right capsular hemorrhage (18 ml), preserved, entered ileal rehabilitation ward 16 weeks ago, neurologically mainly left hemiplegia/sensory palsy, mild higher functional impairment, balloon removal 2 months after onset.
② Psychological aspects		Medical clerk at a clinic until 2 months before onset, hobbies include travelling and eating (162 cm/127kg), 3 weeks after onset, wanted to go to her child’s sports day in a wheelchair, wanted to return home early and drive a car, easily fatigued due to back pain, no independent training.
③ Environmental aspects		Lives with husband and two children in 5th and 3rd grade; husband works at shipbuilding, 1.5 hours away every day; he is a bystander and hopes that she can move around by herself and take care of the house; home is one-storey and barrier-free; she required long-term care 4 a month ago; considering disability certificate and disability pension when the time comes; home visit 2 weeks ago, discharge scheduled 2 weeks later; contacted care manager; scheduled 3 visits a week for rehabilitation; 4-position cane purchased at her own expense; care rental includes ultra-low bed, wheelchair, touch-up, bath board, etc. Four-position cane purchased at own expense; nursing care rental includes ultra-low bed, wheelchair, touch-up bath board, etc.
④ Functional impairment issues		BRS upper limb III - fingers I-II, lower limb III, grip strength right 32/0Kg, HDS-R 26/30, at risk of falling due to attention disorder and low awareness of illness, looked after for 30 m with a four-position cane, “I get tired and my legs get heavy at once”
⑤ Issue identification	Awareness of the issues	Opinion on pre-discharge coordination and future rehabilitation Reconsider?
	Response on the day Intervention points	Shared goal setting using the ICF (International Classification of Functioning, Disability and Health) in day-care rehabilitation, linking pre-discharge and post-discharge. To link, the principle of self-determination and visualization of step-by-step procedures are necessary. Functions: the focus is on upper limb hand function and care is shifted from a disused hand to an assisted hand. Activity: from watching over the four-position cane to independent walking with a walker and out of a wheelchair. Participation: role activities as a wife to her husband and mother to her children.
	Three-day reflection Best practice	Rehab professionals make appropriate adjustments to the person’s involvement on admission and before discharge. Physical fitness problems with a limit of 10 minutes of standing retention are increased to 20 minutes or more before housework activities. To walk safely without supervision, try a forearm-supported walker (for taller people). Self-stretching of the paralyzed upper limb with the wrist and elbow in extension and the shoulder in external rotation for load bearing. To lose weight, repeat the habit of grasping the handrail with both hands, standing up and sitting down, and sweating a little.
⑥ Goal setting		Distal monitoring of walker walking after 1 week, wheelchair withdrawal and independent in-hospital walker walking after 2 weeks, semi-daily activities in day rehabilitation after 3 weeks, self-care of paralyzed upper limb and 100 standing and sitting exercises after 4 weeks.
⑦ Communication		Rehab professionals adjust how and when to proceed with rehabilitation at the appropriate time (Lessons learned).