A Guide for Transitioning to Home After a Rehab Stay

Transcription

1 A Guide for Transitioning to Home After a Rehab Stay

2 Transitioning home after a rehab stay can present unique challenges for patients and/or their caregivers. Patients who have had a debilitating illness or undergone a surgical or medical procedure that requires a rehab stay, all recover differently. Some patients may have co-morbidities or health conditions that complicate their recovery. Some patients who have had a rehab stay may find they have not recovered completely. This can put them at risk for everything from falls to compromised nutrition. Other limitations or restrictions, such as giving up driving or special medication regimens, can make accessing follow-up health care more difficult. The length of stay at rehab varies from patient to patient. To give yourself or your loved one the best chance of making a smooth transition to home after a rehab stay requires advanced planning. Also, it is important to take the time to do it right. The intent of this guide is to help you to quickly understand your options, know what questions to ask your health care team, and to use that information to create a successful transition plan.

3 Let s Get Started Before you can develop a plan, there are some important questions that you need answered. We suggest reviewing this list and obtaining the answers from your healthcare team. Questions to Consider: 1) How long does it typically take to recover from this type of illness or procedure? 2) What restrictions will you have and how long will those be in place? 3) Will physical, speech, or occupational therapy be required? If yes, can it be arranged through home health care, or with an outpatient facility? 4) If you or your loved one lives alone, will you need additional safety precautions or durable medical equipment? Are you mobile? Will you be able to care for your own physical needs including bathing, dressing, and meal preparation? 5) How will you get to appointments, therapy, pharmacy, and grocery store? 6) Will your medications interfere with activities of daily living (make you dizzy or tired)? Once you have a better idea on what to expect after your rehab stay is over, you will be able to begin planning your recovery.

4 Planning for Recovery: When you know ahead of time that you or a loved one will be going to rehab, you have the advantage of being able to prepare and plan. You can fully explore your options for recovery after your rehab stay. Knowing what is available ahead of time will make it easier to deal with unexpected events in your recovery, like complications from medications, extended recovery time, or complex wound care. If your loved one is already in rehab, this guide should help you to quickly understand and evaluate your options for when you are discharged home. Those options can include a wide variety of patient care ranging from home health services to outpatient therapy. Keep in mind, the health care staff is ready and willing to help you through this process. Contact your rehab care manager, social worker, or discharge planner as soon as possible so this transition is smooth and not stressful and hurried. Remember, both caregivers and the rehab patient will be tired and stressed already!

5 Home Health Services: If you will be homebound and will still need skilled services from a nurse, physical or speech therapist, home health services may be the answer. will coordinate with Home Health Services to accommodate your specific needs, but here are some considerations: A physician must certify the services are necessary. Your certifying physician needs to review and provide direction for the care provided by the home health agency. This is often done in conjunction with the home health agency s own medical director or physicians. The home health agency providing the skilled services must be Medicare certified or a provider contracted with your insurance company. The patient receiving the services needs to be homebound. This requirement is often confusing for patients. Homebound is NOT the same thing as bedbound. Under Medicare, homebound means that you can t easily leave your own home and that you are advised not to because of your medical condition. You may leave for medical appointments and for infrequent, short, non-medical reasons such as religious services. Other services, such as respite or home assistance with meals and laundry may be available, but not covered by insurance. Home health agencies bring recovery services to you or your loved one in the privacy of your own home. Examples include a nurse to help with complicated wound care or a physical therapist to help you regain strength and mobility. This option is best for those who have a caregiver or are able to safely stay at home alone.

6 Outpatient Therapy Services: Patients who do not meet the Medicare guidelines for home health care, or who aren t interested in home health care, may benefit from outpatient therapy. Local outpatient therapy clinics provide physical, speech, and occupational therapists to help you continue with your recovery and get stronger while you are at home. The two major barriers to patients receiving outpatient therapy are transportation and therapy caps. Transportation. While some hospital based outpatient therapy programs offer patients transportation through the hospital s transportation department, the majority of outpatient therapy clinics typically do not. Patients who wish to receive outpatient therapy must have their own means of transportation. Therapy Caps under Medicare. The therapy caps may be another drawback if a patient will need prolonged therapy to fully recover. If you have original Medicare (and not a replacement Medicare product), you will be able to receive $1,920 of physical and speech therapy (combined) or $1,920 of occupational therapy before you reach the Medicare cap. After your yearly Medicare Part B deductible is met, Medicare will pay for 80% of these services. The patient will be responsible for the 20% co-insurance. There are exceptions made to the therapy caps. You can learn more about therapy cap exceptions at Medicare.gov ( Your outpatient facility can assist you in figuring out your private insurance allowances and limits for therapy.

7 If you have questions regarding your pending rehab stay, can help. Simply call and we will help you plan a smooth transition from rehab to home.