From Hospital to Rehab: Ensuring the Best Transition for Your Loved One

The last two weeks we have been talking through the hospital discharge process. Two weeks ago we started looking at the hospital discharge process and what potential discharge destinations would be. You can find that post here. Last week we took a look at who, how and when to ask questions regarding discharging from acute care and when to follow up. You can find that post here. Today we are going to discuss  how to find the right fit for rehab and what to expect if your loved one is transitioning to short term rehab. Here we go!

So, it looks like your loved one is headed to rehab. This can be a great opportunity for them to get stronger and regain their independence prior to heading back home. This will also give you more time to make sure home is ready for mom before she arrives. 

Now the main goal is to find out what options are available for rehab and make the best choice for your loved one.

Depending on the type of insurance coverage, the options for rehab may be limited. Most facilities will accept traditional medicare, but options may be limited or have additional costs for Medicare advantage plans such as Humana, AARP, Blue Cross, Kaiser or Cigna. This isn’t the place to have the health care discussion, but usually traditional medicare provides the most options for seniors in most situations.

Don’t worry too much about it now, the case manager will only present options that will accept their insurance and have an open bed. This is what they do. Once you are presented with the options, it is a good idea to call the facilities and schedule a time to quickly tour the facility.

Things to check out or ask about during a tour of a rehab center:

1. Cleanliness of the facility: Do you notice people actively cleaning the facility? In my experience, a general feeling of cleanliness or dirtiness is usually remarkable.
   
2. Attitude of the employees: The person who is showing you around the facility should definitely be smiling, helpful and cheerful. It is their job to put a good spin on the facility. Ask to tour the facility and pay attention to the attitude and pleasantness of the rest of the staff. Do they seem happy to be at work, or do they appear to much rather be anywhere else? Not everyone has to have a great day at work every day, but the general feeling you observe should be that most people enjoy their job and are happy to be there. Pay special attention to nurses, CNA’s and therapists as they will be the ones caring for your loved one.
   
3. Proximity to family and or friends who could visit: Leaving the hospital and not going home is very difficult for most people. It can result in increased anxiety and or depression. Having friends and family close enough to come visit can be a great help. I have also observed that patients who have family around most often tend to receive a little better care. This is not necessarily on purpose by the staff, but having someone there to advocate for your loved one goes a long way. Patients often can feel like a burden even though they are not and tend not to speak up for themselves as often as they should. Families, especially children, can do a good job bridging the gap.
   
4. Experience/Longevity of staff: Ask how long people you interact with during the tour have been at that facility. If the whole therapy staff just graduated from school, they may not yet be comfortable in their roles to provide the best level of care. Turnover can be very high in healthcare, so a facility with staff who have been there for a few years can show a more stable environment and this is usually indicative of a higher quality rehab outcomes for patients. Healthcare providers tend to stay where they feel they are making a difference in their patient’s lives.
   
5. Services offered/Activities other than rehab: Most of the time, therapy will be provided 5 days a week. Are there other activities to help pass the time between therapy sessions? Activities can foster community and help patients break through the loneliness and depression that can be associated with being stuck in rehab when all their friends and family are at home.

Talk to your loved one. Let them know what you find. Go through the pros and cons of each option and make the best decision you can with their input. If they feel that they are part of the process, they will be more likely to “buy in” to the rehab. This improves participation and outcomes for your loved one.

What to expect when they get to rehab:

Once a discharge destination has been determined, your loved one will be taken to the rehab facility. Their medical records will be sent to the facility along with doctor’s orders for medication and anything else that may affect their rehab stay. In the new facility, they will be assessed by the doctor, the nursing staff and physical therapy, occupational therapy and speech therapy. This is required to happen in the first three days, but usually happens in the first 24 hours. Then each therapy discipline will set up a plan of care based on the needs of your loved one. They will likely have therapy 5 days per week and begin to show progress in preparation for transition home!

That's all for today.

Take care, keep mom safe at home and have a great day!

Winn

Articles of Interest:

1. AGE IN PLACE DESIGN GUIDELINES MADE ACHIEVABLE FOR THE ELDERLY
2. HOW ELDERLY HOME CARE MAKES AGING IN PLACE POSSIBLE FOR SENIORS
3. 5 SAFETY TIPS IN THE KITCHEN FOR SENIORS AGING IN PLACE