It’s Discharge Time at the Rehab Facility – Now What?

Discharge planner at Rehab facility with senior woman patient

Transitioning a loved one home from a rehabilitation facility can be a stressful time for families. There are a lot of moving parts involved. Not only is it emotionally stressful, but if not handled effectively, the transition home can lead to exacerbation of health issues and increase the likelihood for rehospitalization.

Here are some tips to make it transitions back home from rehab as seamless as possible:

Plan ahead
Meet with the discharge planning team at least a week ahead of time and carefully review your loved one’s progress and then have ongoing check-ins with the team until discharge day. Be realistic about the goals and expectations, bearing in mind that rehab will continue in the home setting and later as an outpatient in the community.

Carefully review the proposed discharge plan
Read the plan carefully to ensure that it is safe and workable. Know the functional and cognitive capabilities of your loved one and what assistance they will need to accomplish their activities of daily living and rehab goals and check that it makes sense with the discharge plan.

Thoroughly evaluate and assess the home ahead of time
Take a look around your loved one’s home with a critical eye. Make sure it can accommodate any functional limitations and is maximized for barrier-free care. In consultation with the physical therapist and occupational therapist, put together a list of equipment that may be needed to make the home safer. This may include a hospital bed, a bedside or frame toilet commode, a walker, or the installation of grab bars in the bathroom. Take measurements at home – especially important are doorways, beds, tubs, showers and toilets. Find out what equipment will be covered by insurance and what you are expected to pay for. Arrange for large equipment – like beds – to be delivered ahead of the discharge day.

Access and/or hire home care resources that best match your needs and budget
This includes private hire aide care or home health care services covered by insurance. Most insurances will not cover caregiver costs for any significant period of time unless your loved one qualifies for Medicaid or has a long-term care insurance policy. Home care is most often provided by family members or by private hire caregivers sourced through a home care agency or placement agency. Discuss your loved one’s specific needs with the director of the home care or placement agency and ask about the personality qualities and caregiver experiences that may be the best fit for your loved one. Have the caregiver(s) train with the rehab and nursing team before discharge so that they are familiar with care routines.

Arrange for needed supplies ahead of time
This may include incontinence products, monitoring equipment or setting up a food delivery service.

Have a plan to manage medications
If your loved one is cognitively or physically unable to track and fill medication prescriptions, medications can be sorted and arranged in weekly boxes by a designated family member or nurse care manager. Caregivers can then cue their client to take the medications at the correct time. For less impaired clients, there are automated medication dispensers or pill reminder services.

Ensure there is an appropriate plan for transport
When discharge day arrives, make sure your loved one has transportation that will take into account any physical limitations so that entry to the home is accessible. Have a plan for community transport such as wheelchair accessible cabs, cars or ambulettes for follow-up appointments with doctors in the community.

Be knowledgeable on local resources available
Many communities have resources that can help you and your family member such as help with transportation, financial assistance, counseling, support groups, volunteer visits and respite care (time away from caregiving for family caregivers).

Consider appealing the discharge
If you think your loved one is being discharged too soon or to an unsafe community situation, speak up! 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. You can also find this information online. Appeals often take only a day or two. If the appeal is denied, then insurance will not pay for those additional days. Also, your family member will have to leave the facility immediately or private pay for the continued stay.

Consider hiring an Aging Life Care professional 
A professional care manager can help you navigate the transition process. They are particularly helpful if you live far away from your loved one or you are unable to spend the time necessary to ensure that this complex process goes smoothly.

Written by Anne Sansevero