Key Takeaways
- Transfer a functional baseline across physical, cognitive, communication, swallowing, self-care, psychological and participation domains—not just a diagnosis and a list of exercises.
- Preserve measurement conditions. “Walked 50 metres” means little without the aid, assistance, surface, oxygen, pain, rest breaks and safety response.
- Every exercise needs dose, technique, assistance, stop rules and progression criteria. A translated name or video alone is not a prescription.
- Confirm that a named provider at home has reviewed the plan, can deliver the required disciplines and has accepted the first appointment. A referral sent is not a handover received.
- Test equipment, caregiver skills and the real home environment before travel, and create a bridge for any gap between the last session in China and first session at home.
Content
Rehabilitation plans often cross borders as a few exercise names: “gait training, strengthening, balance.” That tells the next therapist almost nothing about the patient’s actual ability, the assistance used, the risk accepted or the next decision.
The object of handover is not the exercise sheet. It is the patient’s functioning trajectory.
Build a seven-domain function passport
WHO’s International Classification of Functioning, Disability and Health treats functioning in context and includes environmental factors [1]. Use that logic to record seven domains:
Domain · What the receiving team needs
body function and symptoms · strength, range, sensation, pain, tone, endurance, cardiorespiratory limits
mobility · bed movement, transfers, standing, walking, stairs, wheelchair and falls
self-care · washing, dressing, toileting, eating, medicines and household tasks
cognition and communication · attention, memory, executive function, speech, language and communication support
swallowing and nutrition · safe textures, strategies, tube status, aspiration concerns and weight/intake trend
psychological and behavioural · mood, fear, sleep, adjustment, safety awareness and behaviour triggers
participation and environment · home roles, work, study, caregiving, transport, housing and social support
Mark what is independent, requires supervision, needs one-person or two-person assistance, or should not be attempted. Avoid “independent” when the patient succeeds only after cueing or with equipment.
NICE recommends functional assessment before discharge that includes physical, sensory, communication, psychological, social-care and equipment needs, with goals agreed with the patient and caregiver [2]. Cross-border transfer should not reduce that assessment to a muscle grade.
Freeze the measurement conditions
A number is comparable only when the test is reproducible. For each formal measure or practical task, record:
- instrument or test name and version;
- date, assessor discipline and language used;
- footwear, brace, walking aid and oxygen;
- physical assistance and verbal cueing;
- distance, surface and turns;
- pain, fatigue and rest breaks;
- reason the test stopped;
- any safety event.
If a score is translated, retain the original form and language. Do not convert between scales unless a validated method exists. The receiving therapist can then repeat under similar conditions and distinguish real change from a different testing setup.
Video can add context when the patient consents and the institution permits it. Label the date, task, assistance and device; remove unrelated people and sensitive information; transfer through an agreed secure channel.
Write goals as observable decisions
“Improve mobility” is not a goal. Use a five-part sentence:
By [date], the patient will [task] under [conditions] with [assistance/device], so that [real-life purpose].
Examples include transferring into the home shower with one rail and standby assistance, or walking from bedroom to toilet at night with a specified aid and no loss of balance. The purpose stops rehabilitation from becoming a collection of clinic tricks.
Keep three levels:
- immediate travel-readiness goals;
- first four-to-six-week home goals;
- longer participation goals such as returning to work, study or caregiving.
Add who owns each goal and when it will be reviewed. Patient priorities belong in the plan even when they differ from a clinician’s preferred metric.
Transfer the rehabilitation prescription
For every active intervention, state:
- clinical target and rationale;
- starting position and technique;
- sets, repetitions, duration, intensity and frequency;
- equipment and assistance;
- permitted symptom response;
- stop or escalation rules;
- progression and regression criteria;
- precautions from surgery, fracture, cardiac status, swallowing or devices;
- discipline responsible for review.
Do not translate brand names for equipment or vague labels such as “electrotherapy.” Identify the device or modality, parameters when clinically necessary, treatment site, purpose and safety boundary. The receiving clinician may appropriately choose a different method to reach the same goal.
Separate maintenance, restoration, compensation and prevention. A brace used temporarily to protect healing is not the same as a long-term compensatory device. An exercise to maintain range has a different success measure from training intended to recover a task.
Use gates between phases
Calendar dates can suggest when reassessment is due; they should not automatically advance the patient. Define entry and exit criteria for each phase, such as:
- wound and medical stability;
- pain and swelling response;
- weight-bearing or movement restriction;
- transfer and walking safety;
- physiological response to activity;
- cognitive carryover and ability to follow precautions;
- caregiver competence;
- equipment and environment readiness.
Record what causes a pause, regression or medical review. A new neurological deficit, chest symptom, uncontrolled pain, wound change, fall or device problem is not solved by reducing repetitions without assessment.
China’s policy on developing rehabilitation medical services emphasises an integrated, tiered and continuous service system [3]. For an international patient, that continuum must be reconstructed deliberately across different providers and countries.
Match the receiving service before departure
Send a concise case pack to the proposed provider and ask for an explicit response:
- Which disciplines are available—rehabilitation medicine, physiotherapy, occupational therapy, speech-language therapy, psychology, prosthetics/orthotics, nursing or nutrition?
- Can the service manage the diagnosis, wound/device and current assistance level?
- Is home, outpatient, day or inpatient rehabilitation appropriate?
- Which prescription, referral, insurance authorisation or translated document is required?
- What is the first confirmed appointment?
- Who handles clinical deterioration before that appointment?
NICE’s 2025 neurological rehabilitation guidance calls for both a key medical contact and an initial rehabilitation contact at discharge, and for urgent equipment or environmental adaptations to be arranged early [4]. A directory link or unanswered referral does not meet that standard.
Ask the receiving therapist what information is missing before the patient leaves China. This feedback is more useful than sending a large archive after arrival.
Map the real home and community
Request measurements, photographs or a live video walkthrough—with consent—of:
- entry steps, lift and door widths;
- bed height and transfer side;
- bed-to-toilet route and night lighting;
- toilet height, shower threshold and support surfaces;
- kitchen access and meal preparation;
- floor surfaces, rugs and turning space;
- vehicle transfer and clinic access;
- availability of a caregiver and backup.
NICE’s stroke rehabilitation guidance recommends establishing a safe, enabling home environment with equipment, adaptations and caregiver support before transfer [5]. The principle applies broadly even though the exact assessment is diagnosis-specific.
Do not order equipment from a photograph alone when fit, weight rating or configuration matters. Record manufacturer, model, dimensions, settings, accessories, side, patient fit, training completed, maintenance and a local repair/supply route.
Make caregiver competence visible
List the tasks the caregiver was taught, then assess return demonstration:
- transfer and guarding technique;
- positioning and skin checks;
- brace, sling or prosthesis application;
- swallowing or communication strategies;
- exercise cueing without force;
- equipment inspection;
- fall response and urgent escalation.
Separate “observed once,” “performed with coaching” and “performed independently.” Also record tasks the caregiver should not do. A willing relative may still lack the strength, cognition, time or emotional capacity for the planned workload.
Create a shift and respite plan. A programme that depends on one exhausted person is not robust.
Treat the journey as a rehabilitation stress test
Door-to-door travel may require more transfers, standing, sitting and problem-solving than a therapy session. Rehearse the components:
- car and aircraft-seat transfers;
- wheelchair use and pressure relief;
- toilet access;
- limb positioning and movement restrictions;
- managing fatigue, pain and scheduled medicines;
- carrying devices and batteries;
- handling delays without exceeding the safe activity dose.
The fitness-to-fly decision remains a separate medical assessment. Rehabilitation can document function and assistance; it should not independently clear pressure, oxygen, clot or surgical risks.
Prevent the “lost week” after landing
Count the days between the last supervised session and the first accepted appointment. For that bridge, write:
- a safe minimum home programme;
- the caregiver’s role;
- equipment and consumable supply;
- a monitoring log;
- what may progress and what must remain fixed;
- medical and rehabilitation contact routes;
- stop rules and urgent-care triggers.
Remote contact from China may help explain the existing plan, but it does not automatically create licensed treatment in another jurisdiction or replace local assessment. Confirm consent, privacy, clinician licensure and emergency limitations before arranging tele-rehabilitation.
At the first home appointment, the receiving team should verify identity, medical stability, restrictions, equipment and baseline measures before progressing. The goal is not to reproduce every Chinese session; it is to continue the same clinical reasoning with locally available methods.
Close the loop at two checkpoints
Use two confirmations:
- receipt: the receiving service confirms that the documents opened, the referral is accepted and the first appointment is booked;
- clinical takeover: after assessment, it confirms the revised plan, new owner and questions for the China team.
WHO’s Rehabilitation 2030 initiative identifies comprehensive service models, multidisciplinary workforce, functioning information and networks as priorities [6]. Those system principles become very practical in one patient’s handover: no orphan goal, no uninterpretable score and no equipment without an owner.
Medical disclaimer: This guide provides general rehabilitation handover information. Exercises, intensity, precautions, equipment and level of care require individual assessment by qualified professionals. New severe symptoms or rapid functional decline needs medical evaluation, not unsupervised exercise adjustment.
FAQ
Is an exercise sheet enough for the therapist at home?
No. Send the functional baseline, measurement conditions, restrictions, goals, dose, assistance, stop/progression rules, equipment and clinical context. The receiving therapist must reassess before changing the programme.
Should the same assessment scale be repeated after returning home?
Preferably, when it is appropriate and available. Record the exact scale, version, language and testing conditions. If the home team uses a different measure, preserve both rather than pretending the scores are interchangeable.
Can the family continue exercises while waiting for an appointment?
Only the safe bridge programme taught and documented by the team. It should state dose, assistance, precautions and stop rules. Do not add resistance, range, speed or balance difficulty without approval.
What equipment information should cross the border?
Send purpose, manufacturer/model, dimensions or settings, weight rating, side, accessories, patient fit, training, maintenance and consumables. Confirm that equivalent local supply and repair are available.
When is the handover actually complete?
When a named receiving service confirms receipt, accepts responsibility, books an initial assessment and then communicates the takeover plan. Sending a referral or giving the patient a phone number is not enough.
Sources
- World Health Organization — International Classification of Functioning, Disability and Health
- National Institute for Health and Care Excellence — Rehabilitation After Critical Illness: Before Leaving Hospital
- National Health Commission of China — Opinions on Accelerating the Development of Rehabilitation Medical Work
- National Institute for Health and Care Excellence — Chronic Neurological Rehabilitation: Discharge and Initial Contacts
- National Institute for Health and Care Excellence — Stroke Rehabilitation: Transfer from Hospital to Community
- World Health Organization — Rehabilitation 2030