Aging Well

Steps for a smooth discharge home from rehab

Mom finally has a discharge date from Rehab. How can we ensure the transition back home goes smoothly?

Posted Updated
Discharge from Rehab
Liisa Ogburn

If this is mom’s first stint in rehab, you are probably exhausted from daily visits to her bedside and worry over her recovery. You may assume that everyone will rest well again only after Mom has been discharged back home. However, keep in mind there may be new stresses to manage at home. Here are some common questions, as well as tools to help ensure a smooth discharge home.

  1. Mom is desperate to get home. Can we get her out early?
The short answer is yes; however, an important question would be whether this will help or hinder her longterm recovery. Inpatient rehab provides more therapy (physical, occupational, speech) on a daily basis than Medicare would support at home. Medicare provides up to three sessions, provided Mom is progressing towards therapeutic goals, per week outpatient. Depending on availability of mobile therapists and mobility of the patient, some practices will come to the home to provide these services. Ultimately, the physician or physician assistant overseeing Mom's care in the rehab facility can help a family understand their parent's therapeutic goals and how to get the best outcomes.
  • How can we make the transition home smooth in terms of ongoing therapy?
  • Typically, the rehab facility will write up Medical Orders for ongoing therapy and provide a copy to the family and fax a copy to a potential mobile provider. The family will need to be proactive about contacting the practice to schedule the therapy continuing at home.
  • Mom is a fall risk. Does Medicare support any home care?
  • Unfortunately, no. Depending on the case and care needs, Medicare may support mobile therapies delivered at home up to three times per week, and possibly a weekly nurse home visit. The family will either need to stay with mom as she regains her strength or enlist the help of private caregivers.
  • Does Medicare cover any supportive medical equipment?
  • Make sure you ask your parent’s physical and/or occupational therapist if they feel it warranted to order any medical equipment to support a safe discharge home. Depending on the specifics of the case, Medicare may cover a wheelchair or walker, a hospital bed, raised toilet seat or shower chair. If Medicare doesn’t cover it, the rehab facility may have suggestions on where you can find used equipment at a reasonable cost. (Habitat and local thrift stores are often a good source.)
  • Does Medicare cover medical transport?
  • It depends on Mom’s mobility and status. For more fragile cases, where there is a heightened risk of falling, often it does; however, if Mom can be transported by wheelchair and has some mobility, it does not. The family may weigh the pros and cons of transporting mom themselves versus paying for a medical transport. (H2Go, a local company, charges just $36, for wheelchair transportation for distances under 10 miles and a little more for those over 10 miles.)
  • What if Mom's prescriptions have changed after her injury and rehab?
  • Make sure Mom's new prescriptions are transferred to her home pharmacy before discharge. Ensure the pharmacy has what is needed on hand, particularly if the move is happening on a weekend.
  • As many patients coming out of rehab are weaker and at an increased risk for falls, consider if there are additional tools that might help prevent falls and have these in place when Mom arrives.
  • Some tools might include a rental hospital bed with rails or stand-alone bed rails that can be fastened on to the home bed; motion detecting lights near the bed; a bell or bed pad alarm to signal the need for help from someone in another room; a bedside commode--if navigating one's way to the bathroom is risky at night; a walker; night-time incontinence products, like Tena diapers; etc.

    If bringing mom home is too daunting at the moment that Medicare stops services, some rehab facilities will allow the family to move mom to a temporary long-term care bed (for a private pay daily rate). Additionally, some Assisted Living communities offer a respite or "road home" program, which would allow Mom to come on a temporary basis (lasting no longer than 30 days), as she continues to recover strength while receiving around-the-clock supervision, with the goal of returning home stronger. This can also provide time to make modifications to the home that may help.


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