6 steps to Help Plan Discharge Home after Rehab stay

Discharge to home often creeps up on many families making the time of discharge stressful. I have interviewed many familes and often find navigating a discharge home from skilled care or even extended  rehab hospital stay is not easy. Concern over will your  caregiver  support be adequate to meet their needs especially when he or she has had nurses round the clock, can be sobering. Take heart and a breath and turn your anxiety into a checklist with solutions to help you manage this process.

Frequently asked Questions  prior to Discharge Home

1. How do I know when to expect discharge so I can plan?

Usually this is set by the treatment team in  a care plan meeting and the social worker or discharge planner should keep you updated  before the date. Ask them proactively what is  the thought  and be persistent so you know how to plan. Discharge dates often change  as they are determined by your loved ones progress and Medicare critera for continued stay, so keep in close contact with the social worker or discharge planner.

2. Who writes the orders for discharge and at what time?

This is done by the doctor and you need to find out typically when on day of discharge the physician will round and what time you should expect to arrange transport.  If you are the transport person,  plan to be there around the  time of the physician rounds or earlier if you are receiving any instructions. If medical transport is arranged, then find out what time they will be called so you can be prepared to meet them.

3. Who will help me coordinate any  equipment for the home? How will I know what I need?

The discharge planner or social worker  with input  from the therapist can help you  decide what  equipment you may need that Medicare will pay for and  can advise you what other needs you may have that will be your responsibility to  pay privately. The discharge planner or social workery will order the Medicare equipment for delivery to your home at time of discharge.    If home health is ordered they can help after discharge with any additional needs or if you utilize private home care for caregiving services they can do a home visit prior to your loved ones discharge and help you decide along with the caregiver you select.

  Key items to consider  are: 
  1. hospital bed need or bed height challenges
  2. mobility devices like walker , wheelchair, cane  need
  3. bathroom  accessibility and safety  devices need
  4. home layout  challenges like stairs into or within house, floor surfaces for walking  and door widths to accommodate wheelchair or mobility devices.

4. Who will help decide if I need medicare home health services or private home care? 

The discharge planner or social worker will let you know what the treatment team and physician think you need on discharge in regards to home health.  They may also recommend private  home care especially if the care needs require alot of personal care and 24 hour observation.  The discharge planner or social worker can help you arrange orders for home health for nursing visits or therapy.

Home health is intermittent skilled visits  and covered by  Medicare. Private home care offers personal care services from 2 to 24 hours a day depending on your need for a caregiver to support your efforts. Medicare does not  cover private home care. You as the family member will have to research and locate a private home care provider and interview them for services. Private home care is private pay, or coverd  by long term care insurance or Veterans benefits . Many times it is not a bad idea to utilize some private home care services if only for a few days to help the transition home and get on a schedule of care.

5.  How will I get orders for my medications?

The physician will have discharge instructions that include your medication orders.  You may  be able to take home whatever medications are left at the skilled care or rehab setting if they are prefilled.  You will also have to fill some prescriptions.  Knowing how you will organize the medications is important because you have to make sure you follow directions for dosages, time and route. Making yourself a medication record and getting medication organizers or automatic dispensers you fill will make that easier and let you know when you are running out.  Remember check dosages of old medications you have on hand  to make sure you do not substitute the wrong medications.

6.  What else is key in my discharge?

It is important to get  any other instruction or training you need for care at home and make sure you   find out when to have followup up visit with your  primary care doctor and specialists.  You should make your appointment for followup us as this is key in  the recovery process for monitoring care.

 Yes discharge time is stressful but by using this simple checklist you can manage your anxiety with action steps.

One Response to “6 steps to Help Plan Discharge Home after Rehab stay”

Leave a Comment & Start a Discussion