By Jacqueline Huston, RN, Care Coordinator/Case Manager at Twin Lakes Senior Living Community
After a rehab stay you’re ready to go home, so what’s next? While it would be ideal for everyone to return home with no additional services needed, there may be some follow up that is necessary to have the greatest success upon discharge from your skilled stay.
What to Expect
The Clinical Team
Soon after you’ve been admitted you will meet with your clinical team for what some facilities call a ‘care conference.’ This meeting includes anyone working to help you heal and recover. If the skilled nursing facility doesn’t set up a meeting with you within in the first week request a meeting.
This team could include any or all of the following professionals:
- Discharge Planner
- Physical Therapist
- Occupational Therapist
- Speech Therapist
- Family members
- Other Individuals you choose to include
Potential topics to discuss at the meeting should include the following:
- Level of ability during evaluation or when you arrived at the skilled nursing facility
- Advanced Health Care Directive
- Medication review
- Information regarding your primary care physician and future appointments
- Progress thus far in therapies
- How your home is setup and what barriers need to be overcome to make returning home possible
- Projected discharge date
- Where you will be going upon discharge
- What services may be needed upon discharge, both skilled and non-skilled
- Recommendations for added support
- Medicare benefits
- When to expect the Notice of Medicare Non-Coverage notice
- Your right to appeal facility’s decision regarding last covered day
- Answer any questions you may have
Work with the facility staff to schedule an appointment with your primary care physician after your discharge as well as any specialist you need to follow up with.
This is highly recommended to ensure continuity of care. The details of your treatment and any medication changes that occurred can be reviewed by your physician allowing for more informed decisions about your care to be made in the future.
Post Discharge - Continued Services
In order to gain maximum independence upon returning home continued services may be recommended.
Additional therapy may be needed and could be offered in an outpatient therapy facility or, depending on the individual's needs, their own home.
These therapy sessions are generally less frequent than those you receive while in a skilled nursing setting. Some facilities, like Twin Lakes, offer outpatient therapy options upon discharge so that an individual can continue treatment with the professionals they have established a relationship with.
For those that will need additional assistance with their activities of daily living upon discharge, home health services may be recommended. In order to qualify for home health services through insurance, an individual must meet the “home-bound” requirement from Medicare.
Once outpatient therapy has been completed, it may be recommended that progress be maintained by visiting a fitness center and working with a trained professional.
By continuing to strengthen the affected area you may increase range of motion and reduce the risk of further injury.
In order to have a positive outcome from a hospitalization followed by a rehab stay, it's critical that you follow the recommendations of the professionals.
Twin Lakes is a continuing care retirement community in Montgomery, Ohio that provides Independent Living, Assisted Living, Skilled Nursing Care, Memory Support Services, and both Inpatient and Outpatient Rehabilitative Services. If you would like a tour of Twin Lakes contact us at 513-247-1300 or click here to reach us online.