Your parent has spent several days or weeks in a rehabilitation facility after an illness or an injury. Now that the rehab period is ending, what happens next? If your parent is returning home, what kind of in-home care and lifestyle adjustments will be required? Is it advisable for your parent to return home? Would it be better to consider an independent retirement community, assisted living, or a skilled nursing facility?
“The answers to those questions are best addressed when the patient is first admitted to the rehab facility,” says David Siegelman, VP of Rehabilitation at the Hebrew Home at Riverdale by RiverSpring Health in the New York City area. “From the day a patient comes in our door, we start preparing a discharge plan. We have a multi-disciplinary team that meets with the patient and the patient’s family to identify goals that are reasonable and achievable and will lead to a safe plan to transition home.”
The Post-Rehab Transition
“Transition” is the key word, as Siegelman explains: “We don’t like to use the word ‘discharge’ very often, because that has a bit of finality attached to it. Instead, we talk about transitioning—moving to the next level of care and helping the family bridge to the next level together as a team.”
This process involves educating the patient and the patient’s family about what to expect. Often times, Siegelman observes, it is not possible to return the patient to the premorbid status—i.e., the status before the illness or injury. In such cases, it may be necessary to adjust expectations with the optimal outcome being a safe, effective, and successful transition to the home.
Siegelman stresses that often families need to adjust goals for the post-rehab period as circumstances change. “It’s not just about achieving or not achieving a certain goal. The goals have to be fluid. Ultimately the patient and the family have to make the decision of what they want to achieve. It may be to return home, or it may be to transition to assisted living or a skilled nursing facility.”
The patient’s financial resources also are a key consideration. “If somebody has the financial resources to pay for additional help at home or to move into assisted living, those are more apt to become options,” Siegelman says.
In weighing these options, families ultimately must decide what is best for their loved one. “For many, the decision is based on the level of independence and the lifestyle the patient is hoping to achieve,” Siegelman observes. “It is their decision to make. We can’t make that decision for them. Our role is to educate them on the risks and benefits, then to work with them to facilitate a safe transition to the level of care they most desire.”
Rehab focuses strongly on the functional components of recovery. As Siegelman explains, “We want to provide all the training that is necessary to get the patient up and walking, improve their balance, maneuver stairs, being able to dress themselves, and all the other things that are necessary to return home.”
Task modification may be required in some instances. “As an example, perhaps you previously tied your shoelace by placing your leg on your other knee,” Siegelman says. “Now maybe that’s not possible. You may need adaptive equipment, or we may need to teach the patient how to compensate for that.”
Rehab also provides an opportunity to teach patients various aspects of self-care such as medication management. “During rehab, we assess the patient on their ability, and then it becomes about problem solving,” Siegelman reports. “Therapists don’t handle medications with patients. However, they evaluate and address the cognitive, visual, and fine motor aspects of medication management. This is incorporated into their nursing and therapy routine.”
Technology is a great tool that can be used effectively to help patients adapt to their home environment in the post-rehab period. Because almost everyone has a smartphone or a tablet these days, Siegelman recommends they use the built-in camera to video the home—from the front door through all the various rooms.
“Before the patient ever takes a step into the home, we can use that video to address some of the challenges they are going to encounter,” he says. “For instance, some bathroom doors are very narrow. When we see the video, we can say, ‘You’re not going to be able to use your walker to walk straight into the bathroom. You’ll have to turn sideways to get through the doorway.’”
Transitioning to the home is facilitated through the use of a home care agency, which may encompass nursing services, home health aide services as well as physical, occupational, and speech therapy. “It may also include a social worker, if there is a specific need for that,” Siegelman says. “Often transitioning requires work in the home environment. It can’t all be simulated in the rehabilitation facility.”
For a patient transitioning to assisted living, access to home care is equally important. “Many assisted living communities use home care agencies that come in, follow up and make sure various issues are addressed, similar to if the person returned to a private home,” Siegelman observes.
The Hebrew Home at Riverdale offers care options that extend beyond short-term rehabilitative services. This includes short-term and long-term skilled nursing care. “As part of our larger RiverSpring Health organization, we also have a certified home health agency and various housing options from independent living to assisted living,” Siegelman says. “We routinely see people move through our continuum of care. That is something that families look for when exploring their options.”
Research is important when choosing a home care agency or senior living community for the post-rehab period. It’s important that families to do both online and in-person research to make the best decision on behalf of their loved one.
“We recommend that families go on a tour of any facility they may be considering,” says Siegelman. “Look at how the residents are presenting. Do they appear happy? Is this an environment you believe your loved one will enjoy? We recommend that the family weigh the positives and the negatives of various options and then come together to make an effective, safe, happy, and hopefully a successful decision.”
CHIME IN: How has your parent transitioned from the rehab to the post-rehab period?