Seniors in Transition- Rehab Center to Home Health

Patients are spending less time in hospitals nowadays. This is partly because there is an active post-acute network of care providers who can effectively care for patients outside the hospital environment. Patients often follow a course that includes acute care, followed by inpatient rehabilitation and then followed by home health care services. Each level of care has its purpose. And each time a transition is made from one level of care to the next, a patient is best served by good communication between care providers. Patients and families can make sure this happens as it should.
How to Prepare
The best way for you to plan for a rehab hospital transition to home health is to gather care information and keep it handy. Ask for a copy of all your medical information when in the rehab hospital. See if you can access the following information:
1. Your inpatient rehabilitation care plan
2. Your current list of active medications
3. A copy of your discharge orders
If the facility is reluctant to provide you with this information, find out the names of the persons who will have this information and be sure these individuals are contacted by the home health case manager who is taking your case. Being your own advocate can sometimes fill in important information gaps common in today's health care system.
Questions to Ask
While you are still a patient in the rehab facility, ask your therapist(s) for copies of your progress notes. Ask them what recommendations they have for your continued therapy once at home. Not all therapists are trained or use the same techniques. You can help your home health therapist understand what the inpatient goals and exercises were trying to accomplish and align your remaining care accordingly. Orders from the physician will list the goals she desires for you, but the means used by the therapist may or may not continue to be the same. That is where your communication might help you to sustain your momentum.
Selection Tips
When you leave the rehabilitation facility, you will be given a list of home health providers that provide service near where you live. You can choose among any of them. Check Home Health Compare (medicare.gov/HHCompare), a Medicare-sponsored website, if you are interested in looking at the quality performance of the agency you are considering. Also, call the agency and ask if therapists are on staff who have expertise in the treatment of your diagnosis.
Generally, the more you are involved in the transition of care from a rehab facility to home health, the more you will gain. Communications between different health care facilities are often spotty. Even if your information is repetitive to the providers of your care, too much communication is far better than not enough. You recovery will be positively impacted if you or your family become actively involved.