Visiting Angels, Punta Gorda Blog

From Short-Term Rehab to Home: Four Tips for a Smooth Transition

Short-term rehabilitationMany older adults utilize their Medicare Part A benefits by recuperating at a short-term care facility, after a hospitalization. Some older adults have elected to have their hip or knee replaced, and benefit from a short stay where they receive physical and occupational therapy to help them bounce back. Other older adults have a sudden heart attack or stroke that leaves them immobilized for some time. These individuals may use most or all their Medicare days in order to relearn basic function.

Whether your aging loved one had a planned stay at a short-term rehabilitation facility, or not, there can be some adjustment when the time comes to return home. The transition home can be complex and requires careful planning and coordination. The good news is that from the moment your aging loved one is admitted to a short-term care facility, the discharge process is already being planned 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 falls on the patient and their support system. Here are a few tips to consider when helping a loved one transition from short-term care back to the comfort of their own home.

Make Care Plan Meetings a Priority

Once your loved one is admitted to the short-term care facility, a social worker will contact the patient and their family to arrange a care plan meeting. This meeting typically takes place within the first two weeks of admission, and perhaps sooner if your loved one has an earlier anticipated discharge date. The meeting will include the social worker, your loved one’s therapy team, a nurse, and other essential staff. The purpose of the care plan is to discuss your loved one’s progress in therapy, as well as long-term goals. Therapists will ask about your loved one’s home environment, so that they can work on stair climbing or endurance. It’s important that you are present at these meetings so that you can begin to make the necessary arrangements prior to your loved one’s anticipated discharge. Also know that you can request a follow-up care plan as often as you’d like, or you can always ask for updates from the nurse and/or therapy team.

Be a Realist, Not an Optimist

The goal of short-term rehabilitation is to help an older adult return to their previous state of being, prior to the elected surgery or unexpected health condition. Most older adults who work hard in therapy can return to their baseline, and some even improve their health while exercising in therapy. Others may struggle to regain strength and endurance, especially if they had an unexpected fall or stroke. It’s important that as a family member, you maintain a realistic perspective while your loved one is rehabbing. Yes, encourage your loved one to work hard and achieve their goals. However, as they begin to plateau before they’ve reached their baseline, you may need to adjust your expectations. The therapy team is a wonderful resource and can show you and your loved one ways to adapt so that they can remain as independent as possible. Learn to trust the therapy team, knowing that they really do have your loved one’s best interests in mind. You can even ask to observe a therapy session so that you can see firsthand how your loved one is progressing.

Modify the Home Environment

Another benefit to attending care plan meetings and observing therapy sessions is that you can learn from the professionals how you can modify your loved one’s home so that they can return to a safe environment. If your loved one does not qualify for a home evaluation, ask for a home evaluation checklist so that you can evaluate your loved one’s home and report back to the therapy team. The therapists can make recommendations on how to adapt your loved one’s home for optimal safety. This may involve installing grab bars in the shower, ordering a bedside commode, removing tripping hazards, rearranging furniture, or modifying lighting. Before you order any medical equipment, check with the social worker about what medical equipment Medicare covers.

Schedule Follow Up Appointments

Lastly, upon discharge, your loved one will need to see their doctor to rectify medications and may even qualify for home health or outpatient therapy. Your loved one’s discharge team will help walk you through this, but you will need to make the decisions about which home health company and what happens beyond home health. Home health is typically no longer than four weeks post discharge, and consists of a nurse or nursing aide, and physical and occupational therapists. Therapy will continue in your loved one’s home, although not as often or intently as the therapy they received at the short-term rehabilitation facility. Beyond this, your loved one will be on their own once again.

Visiting Angels Punta Gorda understands that caring for someone who is recovering from a major surgery or sudden illness can be a complex task. We offer post-hospital and post-short-term rehabilitation transitional care to seniors in the Punta Gorda and Cape Coral 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 recuperate at home. This type of care plays a critical role in reducing the risk of re-hospitalization. We can begin forming a relationship with your loved one while they are receiving treatment at a short-term care facility, making the transition home seamless and effortless. 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, please contact us today by calling 941-347-8288 Punta Gorda or 239-226-1620 Cape Coral. We want to be a part of your plan for a smooth transition back home.

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