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

Rehab Facility to Home

The Provider's Perspective

The transition from rehab to home is complex and requires careful planning and coordination. Caring for a chronically ill or disabled patient at home is a complex task. Many of the tasks that were previously performed by health care professionals in the rehab unit will now become the family caregiver’s responsibility. Your assistance and guidance help prepare them to perform these tasks at home and assure a safer and smoother transition.

The materials in this section address the family caregiver’s needs for information and assistance when planning for discharge from short-term rehab services and the actual discharge from rehab, and the materials related to admission to home care services. They can also be helpful when formal home care is not involved.

Planning for discharge from rehab in many cases happens immediately after admission. Family caregivers often have an ongoing responsibility for provision and/or coordination of care after the discharge. To be effective partners, they must be included in the process, given necessary information, and have their needs as well as those of the patient considered in a collaborative decision-making process.

The discharge itself is often rushed and complicated and requires a high level of coordination. Discussing the details of the discharge plan and needs for follow-up care with family caregivers is essential and can assure a smoother transition and continuity of care.

Upon admission to home care, health care professionals must obtain necessary information in order to create a plan of care. Identifying your patient’s family caregiver and discussing the situation with him or her can be an important source of vital information about the patient--what happened during the hospitalizations or rehabilitation process, current medications, and other conditions that may affect care.

Family caregivers need to have information about community services and other care possibilities.

These guides are designed to facilitate discussions between family caregivers and health care professionals so that transitions in care can be better coordinated, smother and safer. Each of the guides and forms can be downloaded and printed.

Site MapContactHomeTerms of Use
© 2015 United Hospital Fund