Today, we are going to be talking about transitioning from a short-term rehab facility back to your home. We will be discussing discharge plans, communication strategies, home preparations, and most importantly, advocacy. Now let’s move on to the rest of the show.

 

Rehab facilities are somewhat the norm when it comes to transitioning from hospital to home. If your loved one finds themselves in the hospital, for a scheduled surgery, an unexpected illness, or even a fall, they may be moved to a rehab facility before they are able to come home. Last year, over 530,000 people were treated in inpatient rehab facilities. According to Wauconda Care, a rehabilitation center has the goal of getting patients rehabilitated to a point where they can live and function on their own, so these facilities offer short-term care focusing on equipping patients to get back to their life at home.

 

Many families are nervous about transitioning from rehab back to home. Kevin Smith, President, and COO of Best of Care, Inc. gives us an example of a family experiencing the transition from rehab to home. He says that your 88-year-old mother suffers a stroke in the home she and your dad have shared for 40 years.

 

You rush to the hospital. Mom appears frail. Her speech is slurred. She is having a tough time moving her arms. Yet, she seems to be in good spirits. You’re thankful dad called 911, that the ambulance arrived quickly, and that they caught and treated the stroke early.

 

But you’re more than anxious about what comes next. The hospital’s care manager wants to discharge mom to a rehabilitation facility in three days. From there, she’ll go back home to dad… who has also become increasingly feeble.

 

What was a normal part of mom’s day – bathing, cleaning, cooking, doing errands, moving around the home, walking the dog – is now impossible. You know that for mom and dad to remain in their home and age in place, major changes will have to be made. But where to begin?

 

This scenario plays out thousands of times a week in communities across the country. Having a care plan prior to this experience can help ease anxieties and make the process easier. If you have not yet made a care plan with your aging loved ones, we urge you to make one. For help with creating your care plan, visit our website or listen to our episode, “What is a Care Plan?” on YouTube, or wherever you get your podcasts.

 

Back to the question at hand… where to begin? Really, the answer to this question is to begin before you start. When your loved one first enters the rehab facility, AARP says you should ask to speak with a hospital discharge planner or social worker for help planning your loved one's next steps, care, transportation to their next place, insurance coverage, and payment plans.

 

Next Step in Care recommends discussing the following items with the discharge planner or social worker as soon as you have the chance. With the social worker, you should discuss how much time you can devote to being a family caregiver, whether you will provide all or some of the needed care, whether you can continue to work at your job, or if you will need to take time off, whether you have any health problems or other limitations, such as not being able to lift heavy weights, whether you have other commitments, such as caring for young children, and any and all other questions and concerns you may have about being a family caregiver.

 

According to LeadingAge, during this time, you should also work with the rehab staff and request a home visit from the physical or occupational therapist so that they can assess the living environment and make recommendations.

 

Erin Wuerz, a physical therapist and rehab manager with Kindred Healthcare says that “like anything else in life, the key to success is planning ahead. Discharge planning should start upon admission, and it should be an ongoing dialogue between the family and the rehab team during the length of the stay.”

 

Plan ahead as much as you can. This is also why having a care plan is so important. A care plan takes away the guesswork and lets you and your loved one focus on their recovery. If your loved one is going to need additional care once they are discharged from the rehab facility, now is the time to look into care providers, as well.

 

Communication is key throughout your loved one’s stay in a rehab facility. Ask about your loved one’s progress daily. When tracking their progress, make sure you talk to the staff, as well as your loved one, but also be aware that your loved one may not accurately describe their progress to you. Your loved one may not be lying to you, but they most likely want to be discharged and go home and believe they are strong enough when in reality, they are not.

 

On the opposite side of this, Rehab Select tells us that transitioning home after a stay in a short-term rehab facility can be difficult. Recovery from a serious illness, injury, surgery, or stroke can be a long process, and the thought of going back home before they feel confident about fully managing on their own can be intimidating for your loved one and they may not believe they are ready to leave the rehab facility.

 

If your loved one is nervous about this transition, talk with your discharge planner or social worker about ways you can help your loved one feel more comfortable about their situation. You should also reassure your loved one that you will be there for them throughout this process, and so will their friends and family. They have a support system to cheer them on.

 

LeadingAge says that you and your loved one should expect things to not return to normal once they leave the rehab facility. Unrealistic expectations about being able to return to life as normal can lead to disappointment and frustration. Recovery can take a while, and in some cases such as a stroke, you may need to make modifications around the house or get extra assistance from caregivers in order to safely return home.

 

Recognizing that these adjustments will ultimately result in a safer and more comfortable living environment may relieve some of the stress associated with the transition.

 

Once your loved one is nearing their discharge date, it is time to reevaluate the discharge plan you created when they were first admitted to the facility. Now, with the help of the rehab’s discharge planner or social worker and the staff, you will need to prepare for what type of discharge your loved one will have. According to Next Step in Care, your loved one may be discharged to their home, with no needed services, to their home, with help needed from a family caregiver, or to their home, with help needed from a professional home care agency. The rehab team may also recommend your loved one receive long-term care, such as the care they would receive in a nursing home or assisted living facility.

 

Next Step in Care also recommends getting to know your loved one’s discharge team. Their team includes a doctor, who authorizes the rehab discharge. A nurse, oftentimes this is the head nurse of your loved one’s unit, who will coordinate any education regarding medications and other nursing issues. A social worker that coordinates the discharge, making sure that everything happens when it should. They also take care of and educate you on the many details about the facility’s discharge process. A physical or occupational therapist is responsible for evaluating your loved one’s progress in accordance with both professional standards and insurance requirements, as well as providing the therapy your loved one needs to regain their strength. The last member of your care team is you, the family caregiver. You likely are the one who knows your family member best and will be their number one supporter and advocate.

 

When considering any transition, it’s important to be an advocate for your loved one, and for yourself. If you are not yet ready for your loved one to come home, speak up. Needing more time to make the home accessible and safe for your loved one is something you should discuss with the discharge team and you can come up with a solution together.

 

There is also the possibility that the rehab facility decides to discharge your loved one before you may believe that they are ready to come home. According to Next Step in Care, sometimes the rehab program makes a discharge plan you do not want, agree with, or feel is safe. You have the right to appeal this decision and ask for a review. By law, the rehab program must let you know how to appeal and explain what will happen. Make sure the rehab program provides you with contact information for the local Quality Improvement Organization (QIO) that reviews such appeals. Appeals often only take a day or two. If the appeal is denied, then insurance will not pay for those additional days and your loved one will have to leave the facility immediately.

 

If you do have to appeal a discharge decision and are looking for additional support, reach out to your local senior center and elder affairs department. Both will be able to give you resources and information that can help you during the appeal process and after, whatever the decision may be. The rehab facility can also be a good resource to use, for the appeal process and for the transition home. LeadingAge says that your rehab facility can put you in touch with other community resources. Local communities have a wealth of services such as delivering meals, light housekeeping, transportation, and counseling, all of which will provide a helping hand to you and your loved one while still enabling independence.

 

Advocating for your loved one and yourself is such an important task that we want to make sure you are as prepared for as you can be. AARP recommends they you insist on the three “I’s”: information, inclusion, and instruction.

 

Our first I, Information: Obtain printed copies of all pertinent information, including your loved ones' current medications list and prescriptions, any changes to their medications, and a summary of their visit that includes their diagnosis, treatment, prognosis, surgeries, limitations, and any other pertinent information, rehabilitation recommendations, and discharge orders. You should also make note of any scheduled follow-up appointments and share this information with those who will care for your loved ones next, such as their doctors, facilities, home health aides, and professional caregivers.

 

Our second I, Inclusion: Proactively make certain that you are included in care planning discussions and are informed of changes and decisions. If you have health care power of attorney for your loved ones, you can make decisions for them if need be and you need to know what is happening so that you can make an informed choice.

 

And Lastly, Instruction: Nearly half of family caregivers are expected to perform follow-up medical and nursing tasks, so be sure to ask for detailed instructions and training, which is required by law in some states.

 

Now, let’s say you have received the discharge decision and you agree with it. What do you now? First, make sure your loved one’s living space is ready for them. If they live on their own, do you need to temporarily move in with them to help take care of them? You will need to ensure you have what you need at their home, a bed, clothes, food.

 

You will also need to make sure the living space is accessible and safe for them to get around in. For more information on making sure your home is safe and accessible for your loved one, listen to our Quick Tips episode on Aging in Place on our Official YouTube channel, our website, or wherever you get your podcasts.

 

Any equipment and supplies your loved one will need once they return home should already be there waiting for them before they even leave the rehab facility. You do not want to have to rush to find last-minute specialty equipment that your loved one needs, which is why it is important to obtain the necessary supplies and equipment ahead of time.

 

Some common supplies and equipment your loved one may need after being discharged from the rehab facility are hospital beds, recliner chairs, bedside commodes, oxygen tanks and supplies, incontinence products, skincare items, such as water-free shampoo and soap. The rehab facility may have suggestions on where you can get some of these items, so make sure you talk to them about any necessary supplies and equipment your loved one may need.

 

Supplies and equipment can be expensive and add up quickly. Check with your loved one’s insurance to see what supplies and equipment they will pay for. You can also find organizations in your area that can donate supplies or help you cover some of the costs in some way. Not sure who to reach out to? Start with your discharge team. They are there to make sure your loved one gets back to their best self, and getting the supplies they need will help your loved one.

 

When your loved one comes home, Next Step In Care says that you will likely do certain tasks as part of giving care. It is important that you know how to do these safely. Try to learn as much as you can while your family member is still in rehab. You can do this by watching the physical and occupational therapy staff as they do these tasks and asking them to watch as you try these tasks yourself.

 

Sometimes, the rehab staff will not teach these tasks until the day of discharge. This may not be a good time to learn if you feel rushed or overwhelmed. Learn what you can, and ask who to call if you have questions at home.

 

You might be told to call someone from the rehab program, a home care nurse, or other health care professional.

 

Speak up if you are afraid of doing certain tasks (such as wound care) or cannot help with personal hygiene (like helping your family member take a shower or go to the bathroom). Some caregivers are okay with changing their family member’s diapers while others feel very uncomfortable about doing this task.

 

Think about your own feelings as well as your family member’s. The rehab team needs to know what tasks you can and cannot do so they can plan for any needed help.

 

So far, we’ve talked about what you should do to prepare for the day your loved one leaves the rehab facility. Now let’s move on to what you should expect the day of discharge and beyond.

 

When the discharge day comes, you may need to pay for a service to transport your loved one home, depending on their needs. If they are unable to walk or sit, you may need to find an accessible cab, or something similar. The discharge team can help you pick the right transportation service for your loved one. Health Sense says that you will also need to have a plan for community transport such as wheelchair-accessible cabs, cars, or ambulettes (which are a specially equipped van for transporting disabled or convalescent passengers in nonemergency circumstances) for follow-up appointments with doctors in the community.

 

When your loved one comes home, they may have to eat a special diet and take medications. Talk to your loved one’s care team to make sure you understand your loved one’s nutritional needs and restrictions, as well as their medication schedule. Your loved one’s doctor should give you a list of medications, how long they need to take them, how often they need to take them, and how they should take them. You and your loved one should also be made aware of any side effects that their medications can cause and be on the lookout for them. If your loved one experiences any side effects while taking medications, call their doctor immediately.

 

Medications can also be expensive. Make sure to check with your loved one’s insurance to see what they will cover. If your loved one needs help covering the cost of their medications, again, reach out to the rehab facility and community resources for help. Some medications also have to be picked up at a hospital pharmacy instead of your normal pharmacy. If your loved one has a medication like this, make a plan of how you will get this medication and how often you have to pick it up. Some pharmacies offer delivery, as well, especially during the covid pandemic. Ask your local pharmacy and hospital pharmacy if delivery is an option for you. Getting your medications delivered can help you during this time, as it will be one less thing you will need to do.

 

LeadingAge says that you need to recognize that it's ok to have help and to ask for help. Some people are embarrassed about needing assistance after transitioning home, and some family caregivers think they can take care of their loved ones all on their own. It's important to be realistic about the level of care that will be required, and it's ok to have extra help. Getting help isn't a sign of weakness, but one of strength and care.

 

Amy Goyer, a family caregiver, recognized she needed help and asked for it while caring for her dad. She says that when her dad was discharged from the hospital with a feeding tube, she was given just a few minutes of explanation on how to deal with it. It was complicated, and they were back in the hospital multiple times when it clogged. She received help from the home health nurses, but you can bet the next time they had a hospitalization that she advocated more strongly for the information she needed to do her job as a caregiver.

 

At first, Amy didn’t ask for help and tried to do things on her own. Once she asked for help, she was able to better take care of her dad and gain the skills and confidence she needed to be a better caregiver.

 

Lastly, according to AARP, you need to be realistic about the future. Sometimes rehab facilities are unrealistic about what setting is best for our loved ones, or how much a family can handle in terms of future care. It’s up to you to stay rooted in reality. Ask a lot of questions, observe loved ones in therapy sessions, monitor their medications and assess their capabilities, and weigh it all along with their needs, wishes, and quality of life. You should also assess the home situation and potential facilities realistically. If you can’t provide all the direct care yourself, you are not a failure. You are still doing your job as a caregiver when you coordinate the care. Your loved one has a discharge team in the rehab facility, and they will still need a team once they leave. Line up the support you’ll need from care managers, care providers, family members, and friends and build your team.

 

Throughout the transition, make it a high priority to take care of yourself. As we have said an ample number of times and will continue saying, you cannot provide the best care if you are not your best self. While some transitions go more smoothly than others, no transition is perfect. Just do your best with the information you can gather. You can always make new decisions as the situation changes. Plan early, plan often, and be there for your loved one, because at the end of the day, that’s the most important job you have.

 

 

We want to say thank you for joining us here at All Home Care Matters, All Home Care Matters is here for you and to help families as they navigate these long-term care issues. Please visit us at allhomecarematters.com there is a private secure fillable form where you can give us feedback, show ideas, or if you have questions. Every form is read and responded to. If you know someone who could benefit from this episode, please share it with them.

 

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Sources:

https://www.aarp.org/caregiving/home-care/info-2021/transition-from-hospital-rehab-home.html

 

https://data.cms.gov/provider-data/dataset/ka5z-ibe3

 

https://waucondacare.com/2017/08/14/nursing-home-vs-rehabilitation-center-benefits-choosing-rehab-center/

 

https://leadingage.org/members/5-tips-transition-smooth-move-rehab-home

 

https://blog.rehabselect.net/transitioning-home-after-short-term-rehabilitation

 

https://bethesdahealth.org/blog/2019/03/14/steps-to-a-successful-senior-transition-from-short-stay-rehab-to-home/

 

https://www.nextstepincare.org/uploads/File/Guides/Rehabilitation/Going_Home/Rehab_to_Home.pdf

 

https://www.health-sense.org/discharge-time-rehab-facility-now/