Assume no plateau.
Time and time again, the idea of a plateau in post-stroke recovery has been refuted, both in research and anecdotally. It is the responsibility of the therapist to let the patient know that the culmination of therapy this is not the beginning of the end, but the end of the beginning. The patient's rehabilitative efforts after discharge can be confusing, frustrating and not always entirely fruitful. But motivated patients can make gains if they are willing to try new ideas, adapt and research new techniques.
Know the role of the physiatrist and neurologist.
I've asked physiatrists how often they suggest that their patients should schedule an appointment with them, once they've been discharged from therapies. Their answers tend to be all over the place. "If there is a change in function," or "If the patient is having an issue with meds," or "Once a year." But when a typical patient with stroke, who is perhaps five years post-stroke, is asked, "Who is your physiatrist?" the usual answer is, "I don't have any problems with my feet."
The fact is that patients with stroke often lose touch with their physiatrists because many don't see the need for a doctor who directed their acute rehabilitation. They know they've "plateaued"—so why would they need the "stroke doctor" (as physiatrists and neurologists are often called)? But there are good reasons to reintroduce yourself to your physiatrist. Only physiatrists and neurologists are trained to measure nuanced change, know about the latest applicable medications, and understand the true breadth of rehabilitative care as it relates to patients with stroke.