Getting the Right Care After a Hospital Discharge
We spoke with Sarah Mitchell, MSW, who spent 9 years as a Senior Living Advisor with A Place for Mom, about her experiences helping seniors and families with hospital discharge planning. Learn more about what questions families should ask, and steps to follow after a senior loved one has been discharged from hospitalization.
Finding the Right Location for Rehabilitation after Hospitalization
After a serious health event that requires hospitalization, many people will need rehabilitation services, such as physical therapy, speech therapy or nursing care until they are fully recuperated.
Many families are not aware that they have choices regarding where to complete rehabilitation, and that it can take place in a variety of settings. Determining the best location for a loved one to do rehabilitation depends on your family situation, personal preference and the availability in your area.
Rehabilitation may be started in the hospital but is usually completed at home, in a relative’s home, at a skilled nursing facility (SNF) or in an assisted living community. The most important factor in determining where to complete rehabilitation is to find a setting that will reduce their risk of hospital readmission while helping them regain their strength and confidence as quickly as possible.
Skilled Nursing Facilities & Rehab Hospitals
Skilled nursing facilities, also referred to as rehab hospitals or nursing homes, are for people who require 24-hour nursing services and skilled medical care. SNFs offer short-term rehabilitation stays that may be covered by Medicare, for up to 100 days. In order to have your stay covered by Medicare, you must enter a Medicare-approved SNF within 30 days of a hospital stay that lasted at least three days. Many skilled nursing facilities have a hospital or clinical feel with hospital beds and shared rooms. If your loved one is confined to a bed, or requires extensive nursing services, a skilled nursing facility is the best option. Read more about what to look for in a SNF in the Nursing Home Checklist.
Most people do not understand the difference between home health and home care workers. Essentially, home health services are provided by licensed medical professionals who come to the home to do a specific task that has been ordered by a physician and is paid for by Medicare or insurance. Home care is classified as non-medical support, typically is not paid for by Medicare, and is for the time and duration that you specify. Some rehabilitation services can be carried out in the home through home health agencies. Visiting therapists or health care workers come once or twice a week to monitor health, administer injections, provide wound care, strength training and physical therapy exercises.
Typically, rehabilitation therapy provided by home health can only be offered a few times a week. For some patients to have a successful outcome, seniors must be motivated to exercise when the therapist is not present. In-home therapies also lack the peer support and socialization that can be provided in skilled nursing facilities and assisted living communities. That support and socialization often gives seniors the extra motivation as they recuperate.
Rehabilitation Care at Assisted Living
Many people are not aware that rehabilitation can also be completed in assisted living communities. Just like at home, home health can come in and provide specific therapies and nursing services which are paid for by Medicare, with the added benefit of 24-hour assistance from the assisted living community staff.
If your loved one requires assistance with activities of daily living such as bathing, dressing or meal preparation after a hospitalization, an assisted living community may be a good rehabilitation option.
Some assisted living communities even offer assistance with complex medical issues that require nursing services. It is common for assisted living communities to have a physical therapy and occupational therapy room in their building so that residents can take advantage of high tech equipment and receive therapy multiple times throughout the day.
For those who expect to go home after rehabilitation, ask about a short-term respite care stay which typically lasts two months or more. When utilizing respite services you can bring as little or as much furniture from home as you would like to make the apartment feel like home. Seniors often find assisted living to be less restrictive than a skilled nursing setting and wonderful for their outlook on recovery.
You may also want to consider a respite stay at assisted living if:
- Your loved one does not need therapy but is not confident enough yet to go home alone. Respite care can allow a senior to have the peace of mind that someone is available 24 hours a day for assistance and for immediate response to emergencies.
- Family is unable to assist with providing care at home because they live too far away, work, or do not have a safe place for their loved one to stay in their home.
- Your loved one has experienced multiple hospitalizations or is at risk to be re-hospitalized.
- Your loved one or family would like comfort in knowing that their loved one is being cared for 24 hours a day and not home alone, at risk for falling, becoming ill, not eating properly, or forgetting their medications.
- You are unsure if going home is a good, safe long-term plan.
We often find that once someone has tried a respite stay, they opt to remain a permanent assisted living resident at the end of the stay. “Trying it out” is less scary to most people than a full-time, move-in commitment up front and something many assisted living communities encourage.
A loved one who requires strength training and exercises from a physical therapist will be a good candidate for assisted living, where therapies that can be covered by Medicare can be carried out. Depending on your state’s laws and regulations, assisted living may be appropriate for someone who needs a special diet of thickened liquids or pureed foods and/or liquids.
Questions to Ask for Your Hospital Discharge Plan
Here are some questions to ask your hospital discharge planner or primary care doctor before your loved one leaves the hospital:
- What therapies will be required?
- What services will health insurance or Medicare pay for?
- Will we need help with dressing or bathing?
- Will we need help with cooking and housework?
- Will my loved one be safe at home upon discharge or will someone need to be with them 24 hours a day?
- What is the average length of recovery time?
- What problems, symptoms and side effects should we watch for?
- What should we do about any potential side effects or problems?
- Who do we call for emergencies and problems?
- What does each medicine do and why is it needed?
- What are the medication dosages, conflicts and side effects?
- Who do we call if we have questions about medical equipment such as oxygen or a walker?
About the Author:
Sarah Mitchell, MSW, has experience in hospital social work and geriatric outpatient care. As an administrator in Assisted Living and Memory Care with one of the top 20 assisted living companies, she acquired an awareness and knowledge of the industry that she found valuable in her role as a Senior Living Advisor at A Place for Mom. Since 2004, Mitchell has used her education as a social worker and experience in senior living to help over 14,000 families find the right senior care.
If you’ve been through this experience, we want to hear your tips for what worked and what you would do differently. We’d also love to hear from health care professionals about ways to make a safe and smooth transition following a hospital stay. Share your advice with us in the comments below.
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