A rehab discharge or hospital discharge can be scary. Don’t do it alone, find 1 great caregiver.

Even under the best of circumstances a hospital stay and/or rehab stay can be challenging, especially when returning home. What was once a normal part of the day – bathing, cleaning, cooking, doing errands, moving around the home, walking the dog – can be temporarily or permanently affected. 

For some, facility-based care may be the only option due to the increased level of care required. The thing is, just about everyone wants to age in place. Sometimes in order to return home, major changes will have to be made after a rehab discharge. 

Planning for what comes next should begin as soon as possible (not at the time of rehab discharge). While in the hospital, and in a rehab facility, you will have access to resources that are much harder (if not impossible) to access once you go home.

Be sure to make the most of these resources. This guide is for a patient or their loved ones to help plan and consider the questions they should be asking when considering a rehab discharge:

Questions for the hospital’s team and for your loved one’s primary physician:

• What is my loved one’s prognosis?
  • This can be a difficult question to ask and has to be tempered with both optimism and the reality of the situation.
• How long (after surgery or treatment) do you anticipate she will remain in the hospital?
• When do you anticipate a hospital or rehab discharge?
  • A great follow-up is what conditions need to be met to ensure a safe discharge.
• How will you coordinate the evaluation and reporting of my loved ones’ condition now? When do they enter rehab? When do they go back home after their rehab discharge? If not you, what physician will be managing their care?
• How will you coordinate the rehab discharge with the rehabilitation center? With the Medicare home care services that I will hire?
  • It is important to remember that you have a choice in the Medicare Home Health you choose and receive. DO NOT HESITATE TO CALL AROUND. Some hospitals have incentives to refer to specific services that may not best meet your needs. 
  • Abby Services is happy to recommend Medicare Services we are working with.

Questions for the hospital discharge manager or social worker about your hospital discharge or rehab discharge.

• What are my loved one’s rehabilitation facility options? Be sure to request more than one. 
• If your loved one is coming directly home for rehab, what do you have to know and do as a family caregiver?
  • Abby Services has private caregivers who can help support an individual returning home after rehab discharge to help them remain independent. Be sure to ask what level of support is recommended.
  • Often the level of support recommended is high. That is to be sure your loved one is safe and has the support they need. With Abby Services once home the patient and their family can evaluate the situation and tailor their hours to best suit and meet their needs.
• Or, if they will go first to rehab and then to their home, what are my options for hiring home health care support?
  • Abby Services private caregivers can support clients while in rehab as well as upon their return home.

Before your loved one is transferred to a rehab facility

• Research the quality and reputation of the rehab facility. Do they carry state and national accreditation? What is their track record – both positive outcomes and negative incidences?
• Tour the facility if possible and meet with the administration and caregivers. If possible, talk to family members of patients currently receiving services in the facility.
• Understand how this care will be paid for and for how long. 

The transfer from hospital to rehab

• Talk to your loved ones, and prepare them for their move from the hospital to rehab.
• Gather a few easily portable items of comfort from their home (a favorite blanket, book; small pictures of family, etc.) to take to their room at the rehab facility.

After your loved one enters rehab

• Talk daily with your clinical contact at the rehab center to determine your loved one’s progress, and to stay abreast of the projected timeframe for rehab discharge. Rehab discharge planning should start upon admission. When do they anticipate rehab discharge? What benchmarks are needed for a  safe rehab discharge? How are they working to accomplish this goal?
• Work with your family to visit your loved one in rehab as frequently as possible, to gauge both their progress and the quality of care they are receiving. Try to meet with the rehab facility’s attending physicians, physical/occupational/speech therapists, and floor nurses at each visit.
• Scent plays a big role in an individual’s well-being. Some facilities may have a distinct scent. Seek products that create a calming and peaceful environment.
• Sound also is an inevitable part of rehab. Your loved one needs rest. Consider getting a sound machine, earplugs, or sound-isolating headphones, to mask the noises in the hall, or their roommate so that they can get the rest they need.
• In anticipation of your rehab discharge begin evaluating home care service options as soon as your loved one enters the rehab facility. Call, email, and interview prospective home care services to determine if they are a good fit.
  • Remember that there are typically 2 types of home care services available. 
    • Medicare: This is paid for by Medicare, and can typically cover services such as RN visits, PT, OT, and wound care.
    • Private: Private services pick up often when Medicare lets off and can be there at your direction and discretion to help with personal care and assistance such as bathing, laundry, homemaking, and meal prep.
• Before your loved ones’ rehab discharge, their doctor may need to do a medical assessment to determine in-home care needs based on the activities of daily living, or ADLs.
• Based on the doctor’s needs assessment, work with the home care agency you select to develop a plan of care for your loved one: What services will be provided, by whom, and how frequently? What portion of home care could be covered by government programs? What resources does the family have to pay for – what will be the out-of-pocket expenses? Based on these factors, develop a care plan and schedule.

How much of my loved one’s rehab stay does Medicare cover?

Medicare does not typically cover long-term care in a rehab facility unless there are extenuating circumstances. Medicare recipients must first be in a hospital for a minimum of three nights, and receive a doctor’s order, to have Medicare cover care in a skilled nursing/rehabilitation facility.

Medicare will pay for your loved one’s stay at a rehab center if they continue to benefit from receiving skilled services. If the patient has reached a level of mobility or health equal to their baseline health condition before the event that sent them to the hospital, Medicare typically will not continue to cover skilled nursing or rehabilitation services within the facility reinforcing the need for rehab discharge planning.

Families whose loved ones have their short-term Medicare benefits expire have three choices:

• Get a doctor’s evaluation and apply for an extension of Medicare benefits.
• Pay for additional nursing/rehab facility care out-of-pocket.
• Or make sure that professional home care services are in place before the loved one returns home.

Coming home after rehab discharge.

Adjusting to the “new normal” is never easy. Bringing a “stranger” in to provide home care can put additional strain (at least initially) on both the elderly loved one and her family.

Here are ways you can help ease the transition:

• Be sure prior to discharge you work with the therapists and discharge planners to evaluate and order any necessary specialty products and or adaptive devices.
  • Common things are a bedside commode that can be used as a shower chair, walker, wheelchair, specialty bed, etc….)
• Make sure that the professional caregiver is a good match for your loved one. This is a primary responsibility of the home caregiver service. 
  • At Abby Services we liken our service to a match-making service. Just like dating, you may not marry the first person you date. If you find your caregiver is not a good fit simply request a replacement.
• Work with the home care agency to evaluate the safety of your loved one’s home. Pinpoint areas of risk: unsecured rugs, floor transitions from room to room, security of bars and railings, seating arrangements, access to the kitchen and bathroom.
• If necessary, hire home improvement contractors to add ramps, railings, and other supports, widen doorways, change sink, toilet, and tub configurations to improve access and safety.
• Consider setting up home security and remote monitoring systems that enable you to stay in touch with your loved one through a video link or a phone app.
• Work with the caregivers the home caregiver service has matched you with. Tell them about your loved one’s likes and dislikes (food, home care, entertainment, etc.).
• At Abby Services we always recommend clients define in their own words what their expectations are so that we may share these expectations with their caregivers.
• Before your loved one arrives home, arrange for the caregiver(s) to meet them at the hospital or rehab facility for a get-to-know chat.
• Ask for the caregiver to be present in the home when your loved one returns from hospital or rehab
• Make time after work or on weekends to spend time with your loved one and her caregiver. Listen to both, separately, to assess how the relationship is progressing. 

Final tips

Making the transition from hospital to rehabilitation to home care can be extremely challenging, especially if the health, mobility, and mental state of your loved one have changed profoundly. Through the process, remember:

• Make a list of questions before each meeting. There are no bad/stupid questions.
• Anticipate and plan the next phase in your loved one’s care long before you approach that step.
• Keep a notebook and record your conversations with physicians, discharge specialists, rehab experts, and the home care professionals you hire.
• Listen to both your loved ones and their caregiver to make sure they are well-matched.
• Give yourself permission to make time for yourself – to rest and recharge. Your elderly loved one and your family will benefit.

Dont forget you are not alone. Abby Services is here to help. Just call to speak with our RN who can help answer questions and guide you down the best path. 239-590-0861