Making a Safe Transition From Hospital to Rehab

If you have a parent or other loved one who will soon be released from the hospital after an injury or surgery, he or she might not yet be well enough to return home, even with the assistance of in-home care. That likely will mean a transition to a short-term rehabilitation facility or nursing home.

If you’ve never had this experience, you may not know what to expect. The following are some important tips, and a few cautionary tales, from caregivers and a patient who have been through the hospital-to-rehab transition.

Before You Leave the Hospital

Don’t let your loved one leave the hospital without being “admitted.” Without the word “admitted” stamped on hospital papers, the stay at the rehab facility is not covered by Medicare. It’s this semantics loophole that left Cat Stone’s mother in severe debt after a 2012 hip fracture.

“Medicare didn’t just abandon my mother — she went to her grave ashamed and afraid knowing they’d stolen her life savings, her security, and her dignity with an undisclosed loophole,” says Stone, of New Jersey, whose mother was living in a Florida nursing home. Stone wrote about what happened to her mother and family for The CoveyClub.

Medicare covers nursing home care if a person over 65 has been admitted and remained in a hospital for three days, counting admission day but not the day of discharge. Since Medicare only picks up the rehab tab for the first 20 days, secondary insurance may cover the $170.50/day co-pay for days 21 through 100.

Know you can request a private room. The hospital’s social worker will place your loved one in the facility of your choosing as long as there’s a bed available. Since a private room doesn’t cost extra, you might want to request one to ensure a restful stay. While many temporary roommates can get along just fine, sometimes it doesn’t work out.

“My grandmother[’s] roommate was not a good match,” says Amie Clark, whose grandmother was in a nursing home near Portland, OR. “Had we not spoken up, she would have had to continue to tolerate a situation that was not healthy for an 88-year-old.” If your loved one ends up in a double room and it’s not a good situation, you can add his or her name to the private-room waiting list.

Plan for a Sunday, Monday, or Tuesday discharge time. Since patients do not receive physical therapy from either the hospital or the nursing home on discharge or arrival days, the prime day to transition is a Sunday. At most facilities, Sunday is a typical off day for therapy, so your loved one won’t miss what he or she won’t get anyway.

By that same calculation, being discharged on a Saturday can ratchet up three missed therapy days: no therapy on Saturday (transition day), no therapy on Sunday (off day) and no therapy on Monday because this is the day department heads assess your loved one’s therapy needs. If the rehab facility doesn’t do assessments on Saturdays, a Friday departure would mean four days of therapy missed.

When You Arrive at the Care Facility

Get direct phone numbers. It may prove difficult to get ahold of the right person with the phone numbers provided in the welcome pamphlet. Since most department heads carry company cell phones, ask for these numbers. Key ones to get: the nursing supervisor, social worker, and the doctor assigned to your loved one’s care.

Schedule advocates. Schedule at least one person — a family member, friend, or perhaps a paid aide — per day to advocate for your loved one, at least until you feel like everything is going well. An advocate helps draw attention to the person’s needs, especially in an environment where nurses and other care staff often are over worked and in charge of a large number of patients. If you hire someone to be an aide for this, just know the service is not covered by Medicare.

Make sure the staff understands your loved one’s mental condition. When transitioning from a hospital to a care facility, many older adults suffer from some level of hospital delirium. The rehab staff may assume that this is who your loved one is and create a misinformed treatment plan. Some of this is inherent ageism, says Catherine Callahan, 68, who says she tackled head-on the assumptions about her abilities when she arrived at a nursing home in Santa Barbara, CA, after major surgery. They “may think you are hard of hearing, confused, and limited in your determination … I stated up front that I have a keen sense of hearing … and was very committed to doing my program,” she says.

Check with your loved one’s doctor. The facility may require an immediate influenza and/or tuberculosis shot. Since your loved one may already be up to date on these, insist that the facility wait for you to get medical records. And, while you’re on the phone with the doctor, discuss medication changes and contraindications.

Look and ask before your loved one takes medicine. Each time your loved one is given medication, make sure you, your advocate or the patient asks the nurse to state the names of the pills. Lana Wolfe’s 81-year old mother was prescribed oxycodone despite an allergy, which was noted on her chart. “She was given this for two days before I found out,” says Wolfe, of Fort Colins, CO, whose mother was in a rehab facility near Denver. Also, a few times “the medication was just left with my mom [even though] the nurse is supposed to wait until the patient actually takes the medication,” she says.

Don’t ever accept “we can’t do that” or “you have to do that” as gospel. Patients have the right to turn down treatment. “Many people assume that they have to follow the doctor’s orders and don’t have a choice, but they do,” says Clark, who is also a former long-term care social worker. Also, a family member or other individual who is legally designated can refuse treatment and make other decisions for a person in the hospital or rehab.

While Medicare’s Bill of Resident’s Rights states that patients have the right to be treated with dignity and respect, sometimes it can be a battle. “Nurses aides insisted that my mother wear a diaper even though she could go to the bathroom on her own,” says Dr. Carole Lieberman, whose 101-year old mother spent time in two Los Angeles-area rehab facilities. “Diapers are easier for the staff … but they infantilize the patients.”

Patients also have the right to ask for treatment. “My speech was unclear … [but] my program did not include speech therapy,” says Callahan. “I never gave up asking for it.” She gave doctors specific reasons for why she needed it, “such as therapists not being able to understand me.” By the second week, Callahan was assigned a speech therapist.

You have the right to read all paperwork before signing. Remind your loved ones that they do not need to sign something they don’t understand, haven’t read, or for which they do not agree.

If you don’t like how your loved one is being treated, go straight to the top. It may be difficult to get the facility administrator on the phone, but keep trying. If the person remains elusive, demand an internal investigation about your loved one’s treatment from the director of nursing or social work.

Transition From Hospital to Rehab at a Bethesda Community

If you or a senior loved one is in need of Short-Stay Rehab, Bethesda could be the solution for you. Each of our six Skilled Nursing Communities located throughout the St. Louis area offers Short-Stay Rehab and Physical Therapy treatments for seniors who are recovering from an injury or surgery.

Our main goal is to provide a smooth transition for each of our patients, and we will work with you to customize a therapy program for your needs. Contact us to learn more about this program.