Next Step in Care: Family Caregivers & Health Care Professionals Working Together

Rehab Facility to Home

About the Transition

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 Short-Term Rehab Services in an Inpatient Setting. It will give you basic information about the discharge process and get you started asking questions. What Do I Need as a Family Caregiver? can help you assess and understand what supports or training you will need in order to help your family member after discharge from rehab.

During a stay in a rehab unit medications often change; our 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. Also important here is the Medication Management Form which lets you keep track of your family member’s prescriptions and over-the-counter medications.

Going Home: What You Need to Know is a simple checklist that can help you get organized. It is a place to note the various tasks and supplies you will need to help your family member at home. We recommend that you review and complete the checklist with a member of the medical team before discharge from rehab.

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.

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. 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.

Once at home, you may also want to review information about HIPAA and Advance Directives. 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.

And, even if your family member signed an advance directive in the hospital or before hospitalization, you should review the document under less stressful circumstances. The guide to Advance Directives can help you understand the different kinds of advance directives and the process for preparing them. This is also a chance to make sure that any specific advance directives, such as do not resuscitate (DNR) orders are prepared and on file for the current care setting. If no advance directive was signed, now is the time to do it.

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.


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