We all know someone who needed to be transferred to a rehabilitation facility (rehab) for continued recovery after an illness, injury, surgery or decline in their level of functioning.  These stays typically last an average of 20 days; however, it could be shorter or longer depending on progress.  Insurance may dictate how long someone can remain at rehabilitation facilities and there are criteria to meet for discharge.  

The planning process for discharge should begin early; before the discharge date is known.  This takes a lot of coordination among health care professionals, the patient and their families.  Unfortunately, not everyone is discharged home functioning at 100%, requiring no assistance.  Some will need support from their family, and some will need help from a home care agency.  There is also a chance that some will require a transfer to a skilled nursing facility or nursing home.  It’s imperative that the resources are set up in advance to ensure a smooth transition.

As a director of nursing for a home care agency for many years, I have witnessed the chaos that can occur with a poorly planned discharge from rehabilitation facilities.  Let’s imagine you are planning to care for your father once he is discharged from a rehabilitation facility after hip replacement surgery.  If you aren’t in the health care field, you may not know the right questions to ask in preparation, and you arranged to care for him in your home during his continued recovery.  

Your father arrives to your home and his mobility is not quite at his baseline.  This requires someone to provide contact guard (or light hands on him) every time he gets up and down from a seated or lying position to prevent a fall.  You say, “okay, no problem, I can handle this”.  Then your father needs help getting up in the middle of the night to use the restroom, and because you weren’t able to assist him fast enough, he had urinary incontinence.  So the quick trip to the bathroom now includes a sponge bath and change of clothes.  

A couple of days later, panic ensues because you are sleep-deprived and realizing you can’t take care of him alone.  This causes stress for you, and for him.  He most likely already feels like a burden, is embarrassed and is sad that he has lost some of his independence.  Now, you are scrambling to find family members to help, or you are attempting to hire a home care agency who can provide staff fast.

This scenario isn’t meant to suggest that rehabilitation facilities don’t do a thorough job with the discharge planning process or that families aren’t capable of taking care of their loved ones.  I see success with this often.  This blog is meant to provide you with valuable education and resources should you find yourself in this situation.  

Ask the rehabilitation facilities questions before discharge…A LOT of questions.  Exactly how much assistance does your loved one need with bathing, dressing, toileting, transferring, walking, personal hygiene, etc?  Ask what equipment is being used and what equipment or supplies you will need at home.  The facility should assist in ordering these for home use.  Inquire if therapy will continue in the home or on an outpatient basis.  Ask if medications have been changed during the stay so you have time to obtain the correct prescriptions and learn about the effects and possible side effects.  

Also, find out what the discharge instructions are and what you should monitor for that would indicate there is a problem.  Having the answers to these questions will paint a picture of what level of care is to be expected upon discharge from rehabilitation facilities.

Coming home after an injury, illness or surgery should be a happy event.  Don’t be afraid to ask a great deal of questions so the discharge is one that includes a big “Welcome Home!” surprise, instead of stressful chaos.  

Need advocacy during a stay at rehabilitation facilities?  Learn how Wellness Strategies Group can help:  https://wellnessstrategiesgroup.com/services/

Want to learn more about inpatient rehabilitation facilities?  Read more from Medicare Resources: https://www.medicareresources.org/glossary/inpatient-rehabilitation-facility/