Denver CO News Articles

November Spotlight

Five Tips for Transition: A Smooth Move from Short-Term Care to Home

Whether you, or your loved one, is preparing to transition from a short-term rehabilitation stay to home, the transition is complex and requires careful planning and coordination. From the moment you or your loved one is admitted, the plan for discharge is already in process. Family caregivers often have an ongoing responsibility for coordinating care after the patient is discharged. Here are a few pointers to consider when helping a loved one, or yourself, transition from short-term care back to the comfort of home.

Attend Care Plan Meetings
When you or your loved one is admitted a short-term care facility, ask the social services case manager when the anticipated care plan meeting is scheduled and make plans to attend the meeting. Most short-term care facilities schedule these meetings for 7-14 days after admission. You also have the right to ask for a meeting sooner, but often more realistic outcomes are identified after your loved one has received at least a week of therapy. During this initial care plan meeting, goals for discharge and progress towards those goals will be discussed. The social services case manager will also begin a discharge plan with you and your loved one. Social services is a valuable resource to you so take advantage of their expertise and knowledge of local senior services resources available to assist you and your loved one upon discharge.

Observe Therapy Sessions
While most patients prefer visitors after therapy sessions, it’s often a great idea to have family caregivers visit during therapy sessions from time to time. This allows your family to see firsthand the progress you are making in therapy and gives your family an opportunity to discuss what they can be doing to support you once you are home. If additional help or adaptations to the home environment are needed, this gives your family time to research, hire, and make necessary changes. Most therapists welcome family to attend therapy sessions, just be mindful that you are here to observe. Make a morning or an afternoon of it; celebrate progress by having lunch or dinner with your loved one after therapy.

Take Advantage of Medicare Coverage
Medicare coverage is certainly confusing. Most patients and family caregivers do not understand what Medicare will or will not pay for in regards to their short-term rehab stay and adaptive equipment needed upon discharge. Again, the social services case manager is your friend and can answer questions you have about your Medicare coverage and adaptive equipment coverage. Before you purchase any adaptive equipment recommended by therapy, discuss what Medicare covers and allow social services to order covered adaptive equipment for you. Upon discharge, all you’ll need to do is load the equipment in your car, instead of running around town trying to track down the recommended walker, wheelchair, or three-in-one commode.

Set Realistic Expectations
Whether you or your loved one found your way to short-term rehabilitation due to a scheduled hip replacement, or through an acute event, such as a stroke, keep in mind that you or your loved one will not be discharging home with the same physical abilities prior to admission. Set realistic expectations from the start. Be honest with therapy about what your life or your loved one’s life looked like beforehand so they understand your situation. Also realize that you or your loved one may not bounce back as quickly and a new routine or lifestyle may need to be established.

Adapt Home Environment for Safety
As discharge approaches, some therapy programs offer a home evaluation, where you, or your loved one, are treated in your home environment. If you do not qualify for a home evaluation, ask your therapists for a home evaluation checklist so that your family caregiver can evaluate your home and report back to your therapy team. Your therapists will make recommendations on how to adapt your home for optimal safety. This may involve installing grab bars in the shower, removing area rugs to prevent falls, or rearranging furniture so that you can safely navigate rooms.
Caring for a loved one who is recovering from a major surgery or illness can be a complex task. Fortunately, Visiting Angels of Denver offers post-hospital and post-short-term rehabilitation transitional care to seniors in the Denver area. Through our Ready-Set-Go Home program, your loved one will receive in-home care and support from qualified caregivers as they continue to recover at home. This type of care plays a crucial role in reducing the risk of re-hospitalization. To learn more about our transitional care services, or other ways in which our team can assist your loved one in the comfort of their home, contact us today, and allow us to be a part of your plan for a smooth transition back home.

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