Hi Denise - my partner had a severe stroke in September 2015 - be pushy regarding gaining information and explore all information about what your father requires - I spoke to the Doctors in the Hospital and Rehab every day - in Rehab I think they saw me coming and closed their office doors because I always had questions, did my research and expected answers and updates (my partner was also pushing himself to get out of there so we were a bit of a formidable team) following on we meet with his GP every couple of weeks to month to discuss what's required, we found a fantastic speech therapist who he likes working with and 6 months on he's about to commence gentle exercise and yoga/pilates with a Personal Trainer who specialises in rehab. I'm also chasing down a Neurologist as he's been left with seizures so we have someone managing his case Your fathers needs will be individual but if you work closely with his GP you'll get there.
My tip is to push for as much therapy as you can get - OT, PT and Speech T. The more your father gets the more the recovery.
My brother had a severe stroke. After hospital he first went to rehab for 4 months before coming home and receiving another 6 months of therapy either at home or at the rehab outpatients. We pushed a lot for his therapy to keep being extended. We were successful because we could demonstrate that he was still improving!
He also had a follow up with the neurologist from the hospital when he left rehab and again one year later (no further appointments made). We got nothing out of these.
He also visits his local GP every few months. He gets extra physio through his GP - 6 sessions from medicare per year.
Most importantly for his care plan are his visits every 3-6 months with the rehab case doctor. The case doctor is the one who agrees or not to the therapy organised through outpatient rehab.
His care plan is now on monitor. At the last visit with his case doctor, she said that further therapy will only be organised if his condition changes. Unfortunately this week he fell and broke his hip, so he is back in rehab and back in therapy.