Rehab Facility to Home

A stay at a rehab unit, whether in a nursing home or a hospital, is always temporary and it is a good idea to start planning for discharge as soon as possible. Your family member might be well enough to leave rehab, but you might not feel ready for this move. The transition from rehab to home can be difficult for both you and your family member and preparation is key. Your family member may need more assistance or have new medications, or your own ability to provide care may have changed.

It is important that you understand and be part of the discharge planning process. The guides in this section will help you. You can read them in any order but here is what we suggest. You can link on any of the guides here or from the menu on the right.

You might want to start by reviewing the guide to Admission to Inpatient Rehab Services as it will provide you information about the rehab process that you might have not been aware about. The Going Home After Rehab will give you basic information about the discharge process and get you started asking questions. What Do I Need as a Family Caregiver? is a form that can help you understand what you will need in order to help your family member after this discharge.

During a stay in a rehab unit medications often change; A guide to Medication Management will help you understand the process of medication reconciliation so that you know what has been changed and what remains the same. Going Home: What You Need to Know is a simple checklist that organizes the various tasks and supplies you will need. This is a lot to think about, but these guides will help you organize this information and plan ahead.

If your family member is referred for home care services, be sure to read Home Care: A Family Caregiver’s Guide so that you have a realistic expectation of what services are likely to be provided.

Once at home, in anticipation for home care services to begin, it is important to review some additional materials. While your family member was in rehab, you had information about HIPAA and Advance Directives. It’s a good idea to review these. While all home care agencies are required to follow HIPAA rules on sharing information, each agency may have its own privacy rules and requirements.  It is important that you understand your rights  as a family caregiver  under the HIPAA law. Our guide, HIPAA: Questions and Answers  for Family Caregivers can help you.

Even if your family member signed an advance directive in the hospital or before hospitalization, you should review the document under less stressful circumstances. And if no advance directive was signed, now is the time to do it. The guide to Advance Directives can help you in the process.

In preparation for home care, it’s important that you review What Do I Need as a Family Caregiver? and ask the home care nurse to help you fill or update this form. A companion piece is A Family Caregiver’s Planner for Care at Home, which will give you a quick way to see who is coming when, and what tasks you need to do yourself, and what will the home care staff be providing. Also important here is the Medication Management Form which lets you keep track of your family member’s prescriptions and over-the-counter medications. Home care is likely to end before you feel completely ready to take over. Our guide When Home Care Ends alerts you to the plans you need to make.

Finally, we recommend that you read Emergency Room (ER) Visits to help you limit  these visits following discharge and to help you understand the way care is provided in this setting.