Whether you planned to recuperate at a short-term rehabilitation facility after major surgery, or you experienced an unexpected stroke that required intense therapy, the transition home can be bumpy. Many moving parts need to come together. The transition from rehabilitation to home requires careful planning and coordination.
The good news is that from the moment an older adult is admitted to a short-term care facility, the discharge process has already begun by the care team. However, care teams rely on families to coordinate care after the patient is discharged. They can make recommendations, but the responsibility primarily falls on the patient and their support system. Here are a few tips to help older adults and their families make the transition from short-term rehab to home as smooth as possible.
Get to Know the Care Team
From the moment a patient is admitted to a short-term rehabilitation facility, they are assigned to a team of professionals. Comprised of a nurse, therapists, doctor, dietician, certified nursing assistants, and social worker, the care team works together to nurture their patient back to health. Get to know your care team and ask about your progress. Families should prioritize attending all care plan meetings. Care plan meetings are typically where discharge plans are made, so it’s important that at least one family member attends.
Attend Therapy Sessions
If possible, families should ask if they can observe their loved ones during a therapy session. This lets families see firsthand the progress their loved one is making. This also allows therapists to ask family members about the patient’s home environment. The more information a therapist has about their patient’s home, the more they can tailor the treatment plan to succeed at home.
Ask for a Home Evaluation
Before discharge, most therapy teams can perform a home evaluation with their patient. A home evaluation is essentially a therapy session completed in the patient’s home. Therapists work on tasks of daily living, such as meal preparation or bathing and dressing, right in the home of their patients. The therapists can determine whether or not their patient is ready to return home based on the home evaluation. They can also recommend home modifications families can complete before the patient’s discharge so that the patient stays safe at home. If a home evaluation isn’t possible, you can still ask the therapy team for their home modification recommendations.
Modify the Home
After a home evaluation has been completed or you’ve received recommendations about home modifications, it’s important for families to complete those modifications before their loved one’s discharge. Work with the social worker to determine what durable medical equipment your loved one needs and what Medicare will pay for. Purchase other adaptive equipment the therapy has recommended. Other modifications might include installing grab bars, rearranging furniture so there’s room for a walker, fixing loose floorboards, or rearranging the kitchen set up to keep items within reach.
Schedule Follow-Up Appointments
Before discharge, ask what follow-up appointments you need to make or have a family member arrange for you. Depending on your rehabilitation goals, you may qualify for home health or outpatient therapy. It’s easy to forget to make those necessary follow-up appointments once an older adult returns home. It also takes time to research home health companies or outpatient facilities to choose which option best suits your needs. Most of this can be sorted out during a care plan meeting, which discusses the patient’s goals, progress, and tentative discharge date. Ask for referrals and know that the social worker is there to help you out. Whether you’re searching for a short-term rehabilitation facility or home care options to help you get back on your feet, Senior Living Solutions is here to help. Our goal is to provide older adults and their families with alternatives to nursing home care. We’ve personally toured and vetted senior communities and providers to help families reduce the amount of time they spend researching options that may not meet their loved one’s needs. We do this at absolutely no cost to you. To learn more, please contact us today by calling 501-650-3013.