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Navigating the Transition From Hospital to Rehab to Home

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Supporting a loved one's journey from hospital to rehab and ultimately back home can offer its fair share of difficulties. Understanding the rehabilitation process and proactively planning for your loved one's stay can pave the way for an easier transition.

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Rehabilitation services offer vital support for older adults recovering from injuries, accidents, surgeries, and illnesses. While this care is essential, the transition from hospital to rehab back home can feel overwhelming.  

There's a lot more to navigating rehab than one might initially think; it can be easy to get lost in the complexity of the process. Today, we want to help clarify how transitioning works so you can best support your loved one. 

We'll explore what rehab is, how to plan for it, and the resources available to your loved one during their stay. By the end of this article, we want you to feel well-prepared to help your loved one successfully transition from a hospital to a rehab to back home. 

Types of Rehabilitation: Which Do You Need?

Rehabilitation is the process of helping an individual regain functionality and ability through various care services. This article focuses on rehab for older adults transitioning from hospitals to back home (or a long-term care facility).

Older adults may need rehab care for many reasons, including recovering from surgery or injury or coping with the symptoms of a chronic illness. Regardless of the reason, rehabs offer an avenue for older adults to regain their ability to live independently after a major health event. 

Most rehab stays have time limits, anywhere from a few days or weeks to a few months. However, some rehab time periods can last well over 100 days. The length of time spent in rehab hinges on many factors, including overall health and age, motivation for therapy and recovery, and the availability of a support network during and after rehab. 

Rehabilitation services are available in a variety of settings, but most commonly, they are offered at a stand-alone rehab center or a skilled nursing facility. Not everyone stays overnight either; there are both inpatient and outpatient rehabilitation services. Rehabs help seniors get care that would not otherwise be available at home or in a long-term care setting like an assisted living facility.

The main focus in rehab is to help individuals improve their strength and mobility, as well as recover from their ailments. Rehabs generally use a blend of therapy, skilled care, and long-term care to help speed up the recovery. 

Common types of care in rehab include: 

  • Physical therapy. Physical therapy focuses on restoring mobility, strength, and function through targeted exercises and manual therapy.

  • Occupational therapy. Occupational therapy aims to improve the ability to perform daily tasks and activities, such as dressing, cooking, and grooming.

  • Speech therapy. Speech therapy addresses communication and swallowing difficulties that may arise due to stroke, neurological conditions, or other health issues. It includes exercises to improve speech clarity, language skills, and swallowing function.

  • Respiratory therapy. Respiratory therapy uses breathing exercises, airway clearance techniques, and oxygen therapy to improve lung function. 

  • Recreational therapy. Recreational therapy uses leisure activities and hobbies to enhance physical, emotional, and social well-being. Some activities may include arts and crafts, music therapy, pet therapy, and group outings tailored to the individual's interests and abilities.

  • Holistic care. Holistic care emphasizes overall well-being, addressing physical, emotional, social, and spiritual aspects of health. It may include therapies such as acupuncture, massage therapy, or relaxation techniques.

  • Nutritional support. Older adults in rehab will often receive personalized dietary recommendations from a nutritionist or dietitian to ensure they meet their nutritional needs.

  • Medication management. Rehab facility staff can help monitor, adjust, and educate patients on proper medication administration to prevent negative reactions and speed up recovery.

  • Psychological support. Coping with illness, injury, or disability can take a toll on older adults' mental health. Psychological support services like counseling, therapy, or support groups can help older adults cope with the difficult transitional process of rehab. 

  • Pain management. Chronic pain is common among older adults and can affect their ability to participate in rehabilitation activities. Pain management strategies may include medication, physical therapy modalities, relaxation techniques, and alternative therapies to alleviate pain and improve function.

  • Wound care. Older adults recovering from surgeries, injuries, or medical conditions may need specialized wound care to help them heal. 

Why Might Someone Need Rehab?

Older adults may need rehab for various reasons. As mentioned before, most receive short-term skilled nursing care because of surgery, illness, accident, or injury. 

Several health conditions may necessitate rehabilitation for 100 days or longer. Here are some examples:

  • Major orthopedic surgeries. Hip replacements, knee replacements, or complex fractures might require extensive physical therapy to regain mobility and strength, which sometimes may take longer than 100 days, especially for older adults or those with pre-existing conditions.

  • Neurological conditions. Strokes, spinal cord injuries, or traumatic brain injuries can leave individuals with significant functional limitations. Extended rehab may be needed to relearn basic skills like walking, talking, or swallowing.

  • Burns. Depending on the severity of the burn, extensive therapy may be needed to restore function and manage long-term effects like scar tissue.

  • Multiple Sclerosis (MS). MS can cause various symptoms, including muscle weakness, fatigue, and difficulty with coordination. Rehab can help manage these symptoms and improve quality of life, but it may be ongoing.

  • Parkinson's Disease. Parkinson's can cause tremors, stiffness, and balance problems. Physical and occupational therapy can help manage these symptoms, but the disease is progressive and may require ongoing rehab efforts.

  • Cardiopulmonary conditions. Following a heart attack, lung surgery, or other cardiopulmonary issues, extended rehab can help individuals regain strength and endurance. 

Rehabs also work well for hospitals. Hospitals offer life-saving and intensive medical services, and many hospitals have limited resources to support all their patients. These services are best allocated to individuals with life-threatening conditions rather than those who need short or long-term skilled care. 

Rehabs are often better suited to handle skilled care that lasts longer than a few days. These facilities and their caregivers specialize in creating a relaxing and revitalizing for older adults, making care services more personalized. 

How to Plan a Transition From a Hospital to a Rehab

Planning ahead of time is crucial when preparing for a transition from a hospital stay to a rehabilitation facility or back home. By taking proactive steps and considering various factors, you can help ensure a smoother transition and better outcomes for your loved one. Here are some key points to consider.

Research Senior Rehab Options in Your Area

Learning about the rehabilitation services available in your or your loved one's area can help narrow your search. There are several types of rehab, including skilled nursing facilities, stand-alone rehab centers, and some nursing homes. 

As mentioned earlier, there are both inpatient and outpatient rehab options. Inpatient rehabs house individuals in addition to providing care. This type of rehab is for those who cannot yet live independently due to medical or long-term care needs. The goal of inpatient rehab is to help individuals regain the ability to live independently. 

Outpatient rehabs are facilities that individuals visit regularly to improve their mobility and speed up their recovery. Individuals in outpatient rehab may be able to live somewhat independently but still need help regaining their prior mobility or functionality. 

The best rehab option for your loved one will depend on their long-term care and rehabilitative needs. Choosing a facility that specializes in the type of care your loved one needs, whether it's post-surgery rehabilitation, stroke recovery, or specialized therapy services, will help them get the most out of this experience. 

During your research, consider other factors as well like:

  • Location

  • Staff-to-patient ratio

  • Available services and amenities

  • Base cost and any fees

  • Reviews and recommendations from individuals who have worked or lived within the rehab facility

Determine Insurance Coverage and Duration

We're all familiar with the often too-high cost of health care. However, insurance can help significantly reduce the cost of care. 

Many traditional health insurance policies will cover some amount of skilled nursing care, usually up to 90 to 100 days. 

Medicare may also cover rehabilitation services offered in a skilled nursing facility. Under current Medicare rules, a hospital stay is required for Medicare to pay for skilled nursing facility (SNF) rehabilitation. 

However, there are a few other requirements to get coverage under Medicare:

  • Minimum stay. Individuals must have an inpatient hospital stay that lasts at least three days (not counting observation days).

  • Reason for admission. The hospitalization must be for a medically necessary condition that requires inpatient care.

  • Need for skilled care. Upon discharge from the hospital, the beneficiary must need skilled nursing or therapy services that can only be provided in an skilled nursing facility setting.

If the above criteria are met, Medicare Part A typically covers a limited number of days (usually up to 100 days with a copayment) in an SNF for skilled nursing and rehabilitation services. The Medicare supplement will pay for the copays on days 21 through 100.

Other insurance options like Long-Term Care Insurance will cover any long-term care or help needed with activities of daily living during this time as well, including rehab if the care is expected to last at least 90 days. You can contact your loved one's insurance provider to further understand their policy, copays, deductibles, or any limitation on services. 

Skilled care and long-term care are both closely tied to rehabilitation. Depending on your loved one's needs, both types of insurance can be essential to getting necessary care at an affordable price. 

RELATED: Doesn't Health Insurance Pay for Long-Term Care?

Understand Admission and Discharge Procedures

While it may not seem obvious, you should start planning for hospital discharge on day one of your loved one’s stay. By considering these factors early, you can proactively address any concerns or logistical challenges that may arise during the transition process.

Your loved one may be discharged from the hospital earlier than anticipated. It’s best to have a rehab, skilled nursing facility, or a viable home care solution planned in advance to ease the stress of the transition. In addition to planning for an early discharge, you’ll also want to familiarize yourself with how admission and discharge work. 

Admission and discharge both require documentation such as medical records, insurance information, or doctor’s recommendations. Without one of the pieces, there could be problems getting proper coverage or admission to rehab. 

Likewise, there are also requirements for discharge from rehab. Individuals have to meet rehabilitation goals, be ready for independent living, and have a plan to maintain their ongoing care needs.

Being proactive can help create a smoother and more successful rehabilitation experience for your loved one. Effective planning and communication with healthcare providers and support networks are essential for achieving optimal outcomes and promoting recovery.

What Should You Do Once Your Loved One Moves Into Rehab?

There are a few steps you may want to take after your loved one moves into rehab to ensure a happy and short stay. 

First, ask if your loved one can have a private room. Rooms in rehab can be shared or private; some facilities may charge extra for a private room. However, it never hurts to ask, especially if you have concerns about your loved one getting along with a potential roommate.

After your loved one moves in, make sure they feel comfortable in their new room. Whether that means wiping down surfaces or adding small decorations on their nightstand, each little piece makes a difference. Feeling more relaxed and comfortable in rehab can help your loved one recover faster.  

It's also essential to get to know your loved one's care team on a personal level. Take down the care team's names and phone numbers, and make sure they're aware of your loved one's needs early on. 

Establishing a connection with the care team early on can help your loved one get a more personalized care plan. It can also help resolve any miscommunications or issues that you may encounter in the future. 

One last vital aspect of rehab is becoming more familiar with your loved one's treatment plan. Be sure to get a copy of any important documentation, including any treatments or medications they take during their stay. This will make it easier for future doctors and care teams to know what does and doesn't work for your loved one.

Transitioning From Rehab to Home

As your loved one's stay at a rehabilitation facility draws to a close, you'll need to plan and prepare for their transition back home. Below, we'll discuss a few tips to make this process easier. 

Create a Safe Home Environment

Before your loved one moves back home, you need to assess and identify any potential hazards or barriers to mobility. Even simple things like narrow stairs, dim lighting, or clutter around the house can be hazardous. 

Modifications like grab bars in bathrooms and arranging for assistive devices, such as wheelchairs or shower chairs, can support independence and safety at home.

You may also want to consider a security or emergency alert system that can automatically contact you or emergency services in case of an accident. These services can provide essential support and peace of mind during your loved one’s time of need. 

Get a Copy of Your Loved One's Home Treatment Plan and Medications List

When you leave the rehab facility, you'll want to get a copy of your loved one's care plan. This plan will outline recommended therapies, exercises, medications, and activities prescribed during rehabilitation. 

This list should also cover any changes or past medications and treatments. It's important to get this list so you can continue their care or help future caregivers learn about what does and doesn't work for your loved one. 

Proper rehab documentation, like a discharge status, is also essential for getting insurance coverage for your stay. You should work closely with your loved one's care team to ensure everything works out on the insurance and financial side of the stay. 

Utilize Support From Professionals

The most important thing to remember is that you and your loved one are not alone in this process. There are support systems and resources to help ease this transition, including home health services, community outreach programs, and support groups. 

These services can help you and your loved one cope with the emotional challenges of long-term care, as well as provide necessary physical assistance such as help with transportation or activities of daily living. 

Professional help works well for many families and older adults. You can use the LTC News Long-Term Care Directory to find professional home caregivers and long-term care services near you or your loved one. 


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How To Navigate Rehab with Your Loved One

Navigating the transition from hospital to rehabilitation and back home can be challenging, but this journey can be made easier with careful planning, support, and collaboration.

Rehabilitation services are crucial in helping older adults recover from injuries, surgeries, illnesses, and accidents. Rehabs can provide specialized care and therapies for older adults to return to their regular lives and routines.

Being proactive about your loved one's care is essential throughout the transition process. Researching rehabilitation facilities, understanding insurance coverage, and anticipating discharge procedures can help create a smooth, stress-free move from hospital to rehab to back home. 

If you found this article helpful, you may want to read more about caregiving and the support available to informal caregivers. 

  • Making a Long-Term Care Budget – Budgeting for long-term care is vital. This article can help you identify what types of care you'll need to prepare for and strategies to save for long-term care in advance. 

  • How To Pay For Long-Term Care – This article discusses different ways to cover long-term care costs, including insurance, savings, and unique funding opportunities. 

  • Caregiving 101: Types of Caregiving and Selecting a Caregiver – Finding a caregiver is essential to everyone's long-term care journey. This article can help you learn about different care services and choose the best one for your loved one.

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