March 16, 2016

Important Steps in Transitioning from Rehab to Home

By Janice Colpitts, Director of Social Work at Leonard Florence Center for Living
You or a family member are in a rehab facility and have many questions about how to prepare for a smooth and safe transition back home. Keep in mind that the transition back to a home environment can be a stressful time. With a little planning, however, there is a great deal that can be done to simplify the process.
Discharge Team
You will have a team of professionals with specific expertise to guide you or a family member throughout the discharge process. This team will typically consist of a medical professional, a social worker, a physical and occupational therapist and you and your family members. This team will address any health issues and other limitations with you in order to understand how best to ensure safety at home.
Planning Meeting(s)
One meeting (or more) will occur to help you and/or your family member plan for the return home. Key points of the discussion include:

  • Review of new medications and how to use them properly after discharge
  • Discussion of community based services, such elder services, including home meals, emergency response system and personal care options
  • Discussion of referral to a home care agency where you or your family member would benefit from the expertise of skilled disciplines such as nursing and/or   therapy at home
  • Evaluation of equipment and supplies needed.  Equipment needs may include items such as cane, walker, hospital bed and oxygen supplies
  • Discussion and education on any special foods or diet changes

Focus on Tasks
There are several tasks for you to focus on to help ease the transition back home. While you or your family member is at rehab, feel free to become involved in the process. Try to learn as much as you can while you or your family member is in rehab.

  • Take the opportunity to watch the physical therapist as he/she helps you or your family member climb stairs or transfer from bed to a wheelchair
  • Feel comfortable asking questions and letting the team know of your comfort level with such tasks as personal care, wound care and medication management. Think about your own feelings as well as your family member
  • Understand what equipment the rehab team will provide and what equipment you need to acquire at home

Become Knowledgeable
Once you and your family member have a plan to transition home, be sure you are knowledgeable of the contacts and resources you may need to access after the transition:

  • Know who to call and what to do. You may have questions the first few days at home. Make sure you know the phone number for the social worker at the rehab facility and the home care agency involved with you and your family member’s care at home
  • You or your family member should schedule a follow-up appointment with his or her primary care physician as well as other new health care professionals. Know when these appointments are scheduled and be sure to attend them to keep your progress on track

Obviously, there is a lot to think about and plan in order to have a safe and successful transition from rehab to home. Just remember that you are not alone in this process. The team of professionals at your rehab facility is available to help you and your family member figure out how to make this transition as easy as possible.