After a health event that requires hospitalization, going home to live independently isn’t always practical, or even safe. Many people will need rehabilitation services, such as physical therapy, speech therapy or nursing care until they’re fully recuperated. Deciding upon the best course for care for yourself or your loved one isn’t always easy to do. It’s important to understand the available options and other issues that need to be considered before making this essential decision.
Rehabilitation may be started in the hospital, but is usually completed at home, at a skilled nursing facility (SNF) or in a rehab center. The most important factor in determining where to complete rehabilitation is to find a setting that will reduce the risk of hospital readmission while you or your loved one regains strength and confidence as quickly as possible. Determining the best location for rehabilitation will also depend on your family situation, personal preference and the availability in your area.
The way the hospital transition is handled—whether the discharge is to home, a rehabilitation (“rehab”) facility, or an SNF — is critical to the patient’s health and well-being.
Only a doctor can authorize release from the hospital, but the actual process of discharge planning can be completed by a social worker, nurse, case manager, or other qualified person. Ideally, and especially for the most complicated medical conditions, discharge planning is done with a team approach.
The basics of a discharge plan are:
- Evaluation of the patient by qualified personnel
- Discussion with the patient or their representative
- Determining whether caregiver training or other support is needed
- Referrals to a home care agency and/or appropriate support organizations in the community
- Arranging for follow-up appointments or tests
The discussion needs to include the physical condition of the person needing rehab, both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home.
It also should include information on:
- Whether the patient’s condition is likely to improve
- What activities the patient might need help with
- Information on medications and diet
- What extra equipment might be needed, such as a wheelchair, commode, or oxygen
- Who will handle meal preparation, transportation and chores
- Possible referral to home care services.
The answers to these questions will help determine the best course of transitional care. Studies have found that improvements in hospital discharge planning, such as following the steps above, can dramatically improve the outcome for patients as they move to the next level of care.
There are three primary aftercare or rehabilitation options available and each has its own rules, regulations, and entrance requirements.
Skilled nursing facility
Skilled nursing facilities, also referred to as rehab centers or nursing homes, are for people who require 24-hour nursing services and skilled medical care. They’re typically the best places to be if the patient’s doctor orders inpatient services, or if the patient will benefit from specialized treatment following the hospital stay, such as intensive physical or speech therapy.
SNFs offer short-term rehabilitation stays that may be covered by Medicare, for up to 100 days. To have a stay covered by Medicare, the patient must enter a Medicare-approved SNF within 30 days of a hospital stay that lasted at least 3 days. If the patient is confined to a bed, or requires extensive nursing services, a skilled nursing facility is the best option.
If you or your loved on needs only part-time or intermittent rehab or skilled nursing services such as wound care or monitoring of medications and equipment, then home health care may be the right option. Depending upon need, care can be provided by nurses, nurse practitioners and physician assistants or certified home health aides.
The decision to use outside help for caring for an elderly loved one is difficult but there are a wealth of senior care resources for you to consider. Often, depending upon specific needs, a non-medical but trained home companion will be able to assist with mobility, medication reminders and special dietary issues. In addition, the home companion offers family members the peace of mind knowing that their loved one is safely at home.
If your loved one’s rehabilitation needs aren’t acute and don’t require inpatient services, then the person needing rehab may be able to take advantage of outpatient services. The patient must be able to travel in order for his or her after-care needs to be met by a short-term rehab center or an adult day health center. Typically, outpatient rehabilitation centers provide physical, occupational, and speech and language therapies.
Sometimes the need is for additional services beyond those provided at the rehabilitation center. Often, a combination of outpatient rehabilitation services and in-home care services works well in this scenario. Also keep in mind that it’s common for top rehab facilities to have waiting lists, so it’s important to start early to find a center that will accept the patient when they’re ready to be discharged from the hospital.
A continuum of care in one place
Some senior living communities combine skilled nursing and rehabilitation, as well as assisted living, services under one roof. Having all of these levels of living on one campus allows people to transition from level to level with ease and peace of mind. Such senior living communities have been able to increase their number of residents because of the availability of a continuity of care. Communities that offer skilled nursing care, assisted living, and rehabilitation are well versed in customer service and patient care. They are able to balance the continued care for patients between levels of service and have an expert understanding of the documentation associated with each level of care. Also, because they so frequently deal with hospital referrals, admissions often happen more seamlessly.
Regardless of the type of facility you choose, always do your research. Don’t be afraid to ask the tough questions:
- How did they rank in their CMS (Centers for Medicare and Medicaid Services) rating? This is an overall rating for the quality of many medical/health care services that falls between 1 and 5 stars.
- How did they score on the last state inspection?
- Do they provide the specific care you need?
- Do you feel comfortable putting your or your loved one’s care in their hands.
While moving elderly people from one setting to another can be nerve-racking for everyone involved, there are things you can do to make it go more smoothly. Understanding your options, as we’ve reviewed here, is a good beginning.
Additionally, AARP has put together a list of helpful tips for managing the transition from hospital to rehab to home. (You can read their full story here.) Their 4 tips are:
- On the day of admission (or before, if possible), start planning for discharge. The earlier you begin considering your options and the questions you’ll face, the better.
- Create a transition checklist. Visit the AARP page for many helpful resources for creating your checklist.
- Realistically assess abilities and get training. You know the patient’s abilities and limitations, so you’re able to best keep the expectations of a facility’s staff rooted in reality.
- Get help planning modifications and care. Talk with an occupational or physical therapist, a certified aging-in-place specialist or an aging life care professional and ask for an evaluation the patient’s home to determine what modifications may be needed.
Some communities offer private rooms for support following a hospital stay in Fairfield County, CT. Ridge Crest at Meadow Ridge offers the Oasis suite, a private pay option, for seniors needing transitional care. If short-term rehabilitation or long-term health services are needed, Ridge Crest offers the highest quality skilled nursing care and maintains an overall 5-Star rating from the Centers for Medicare & Medicaid Services. Learn more by calling 1-866-761-8510 or filling out the form below.