In the event that your loved one may be unable to return to their former home without a stop at a rehabilitation 

residence, here are a few items to keep in mind: 

Selecting a Rehab Facility

A few days prior to discharge the case manager will reach you to introduce themself to you and to explain what

 services are or are not covered by your insurance.  It is appropriate at this time to 

request a private room at a facility, especially if the patient presents with dementia or cognitive decline.  

Within a few days the planner or case manager will provide you with a list of available rehabilitation centers

 that have beds available for you.  You will be given a window of time in which to decide a first, second and 

third choice selection.   

TIP - While rankings (Medicare.gov) are important to evaluate a rehab center, 

the most important qualification is its proximity to the caregiver 

who is most likely to visit. More than ever, the patient will need an advocate 

at the rehabilitation residence!   

Arriving at the Rehab Residence

Be aware that rehab facilities are essentially nursing homes.  So do not be surprised when you walk in the door, and they are not quite what you might expect a therapeutic residence to be.  And if you arrive on the weekend, physical and occupational therapy service may not begin until the work week. 

This is also yet another unfamiliar location.  Clothes and personal effects need to be brought in, and need to be monitored as they are washed and returned by staff.  The patient who has had a long hospital stay will need to be bathed, groomed and checked for bed sores. Sleeping patterns, eating and behavior will once again be off kilter.  Sundowning is extremely prevalent and if mobile, patients are known to wander. Expect to spend extra time with your loved one these first few days to help them get acclimated and comfortable.  Get to know the staff that will be with them on a regular basis.

“A note about guilt - You will feel guilt as a caregiver, especially if you are unable to care for your loved one in your home.  You may project that guilt into criticism of quality, regardless how nice any care residence. The food is awful, the nurses not attentive, the facilities unkept, etc.  Be aware of this.  Take a deep breath. Advocate as much as you can, while recognizing the limitations of the people who are providing care for your loved one 24/7.” - Caregiver from a distance

Leaving the Rehab Residence 

Typically Medicare coverage for rehab residences lasts about 21 days or  3 weeks. (Usually stay length is determined shortly after arrival.) After that time, patients are required to pay out of pocket per day.  Many people will be involved with the discharge from rehabilitation including a Medicare representative.  Make sure to ask exactly what home care services will and won’t be covered post illness once your loved one returns home.  This may require getting written assessment records from the rehab Physical Therapy/Occupational Therapy (PT/OT) staff prior to discharge or upon their arrival back home. Typically, senior or assisted living residences will have partnerships with companies for ongoing pt / ot providers on site, as well as home-care nursing, but make sure to ask for multiple referrals before leaving the rehab center.   

Once the Patient Returns Home or to an Assisted Living

Regardless of where your patient is returning from or to, accommodations may need to be made to increase services and care to ensure a smooth transition back home and return mobility and agility. Several services are available and are covered by Medicare.  Do as much research as possible before your loved one has returned.  For more information and advice about home care services and how to select care professionals, go to the Aging in Place section.  

Winchester Hospital offers traditional inpatient care, but also incorporates a Hospital at Home program to deliver hospital-level care in the comfort of the patient's home. This program allows some patients with acute illnesses or conditions to receive treatment and monitoring in their homes, rather than in a traditional hospital setting.  Other hospitals around the country are also beginning to utilize this approach ask your local hospital if they have a similar program.

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