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Making the transition from hospital to rehab or home

What to know, what to ask, what to do

By Kevin Smith

Making the transition from hospital to rehab or home

Your 88-year-old mother suffers a stroke in the home she and your dad have shared for 40 years.

You rush to the hospital. Mom appears frail. Her speech is slurred. She is having a tough time moving her arms. Yet, she seems to be in good spirits. You’re thankful dad called 911, that the ambulance arrived quickly, and that they caught and treated the stroke early.

But you’re more than anxious about what comes next. The hospital’s care manager wants to discharge mom to a rehabilitation facility in three days. From there, she’ll go back home to dad…who has also become increasingly feeble.

What was a normal part of mom’s day – bathing, cleaning, cooking, doing errands, moving around the home, walking the dog – is now impossible. You know that for mom and dad to remain in their home and age in place, major changes will have to be made. But where to begin?

This scenario plays out thousands of times a week in communities across the country. For more than 30 years our home care agency has advised thousands of families on these kinds of issues. We’ve also helped their elderly loved ones cope with newly-limited abilities brought about by injury, illness or chronic conditions.

Here is an abbreviated primer of questions to ask and issues to consider when helping your loved one transition from a clinical setting back to their home.

While your loved one is still in the hospital

Questions for the hospital’s team and for your loved one’s primary physician:

  1. What is my loved one’s prognosis?

  2. How long (after surgery or treatment) do you anticipate she will remain in the hospital?

  3. When do you anticipate that she will be discharged?

  4. How will you coordinate evaluation and reporting of my mother’s condition now? When she enters rehab? When she goes back home?

  5. How will you coordinate with the rehab center? With the home care services that I will hire?

Questions for the hospital discharge manager or social worker

  1. What are my loved one’s rehabilitation facility options? Give me more than one.

  2. If mom is coming directly home for rehab, what do I have to know and do as a family caregiver?

  3. Or, if she will go first to rehab then to her home, what are my options for hiring home health care support?

Before your loved one is transferred to a rehab facility

  1. Research the quality and reputation of the rehab facility. Do they carry state and national accreditation? What is their track record – both positive outcomes and negative incidences?

  2. Tour the facility if possible and meet with administration and caregivers. If possible, talk to family members of patients currently receiving services in the facility.

The transfer from hospital to rehab

  1. Talk to your loved one and prepare them for their move from the hospital to rehab.

  2. Gather a few easily-portable items of comfort from their home (a favorite blanket, book; small pictures of family etc.) to take to their room at the rehab facility.

After your loved one enters rehab

  1. Talk daily with your main clinical contact at the rehab center to determine your loved one’s progress, and to stay abreast of the projected timeframe for discharge.

  2. Work with your family to visit your loved one in rehab as frequently as possible, to gauge both their progress and the quality of care they are receiving. Try to meet with the rehab facility’s attending physicians, physical/occupational/speech therapists and floor nurses at each visit.

  3. Begin evaluating home care service options as soon as your loved one enters the rehab facility. Call, email and interview prospective home care agencies to determine if there’s a “fit”.

  4. Before your loved one is discharged from the rehab facility, their doctor will need to do a medical assessment to determine their in-home care needs based on the activities of daily living, or ADLs, that will need to be supported.

  5. Based on the doctor’s needs assessment, work with the home care agency you select to develop a plan of care for your loved one: What services will be provided, by whom, and how frequently? What portion of home care could be covered by government programs? What resources do the family have to pay for – what will be the out of pocket expenses? Based on these factors, develop a care plan and schedule.

  6. Meet in advance with the home care team that will be assigned to your loved one. Depending on your loved one’s needs, that team may include a combination of clinical (nurses, certified nursing assistants (CNAs), home health aides), non-clinical (homemakers and companions) and supervisory personnel.

How much of my loved one’s rehab stay does Medicare cover?

Medicare does not typically cover long-term care in a rehab facility unless there are extenuating circumstances. Click here for a full summary of Medicare coverage in skilled nursing facilities. Medicare recipients must first be in a hospital for a minimum of three nights, and receive a doctor’s order, to have Medicare cover care in a skilled nursing/rehabilitation facility. Medicare will pay for your loved one’s stay at a rehab center if they continue to benefit from receiving skilled services. If the patient has reached a level of mobility or health equal to their ‘baseline’ health condition before the event that sent them to the hospital, Medicare typically will not continue to cover skilled nursing or rehabilitation services within the facility.

Families whose loved ones have their short-term Medicare benefits expire have three choices:

  1. Get a doctor’s evaluation and apply for an extension of Medicare benefits.

  2. Pay for additional nursing/rehab facility care out-of-pocket.

  3. Or make sure that professional home care services are in place before the loved one returns home.

Coming home

Adjusting to the “new normal” of limited mobility and daily living needs within one’s home is never easy. And bringing a “stranger” in to provide home care can put additional strain (at least initially) on both the elderly loved one and her family.

Here are ways you can help ease the transition:

  1. Make sure that the professional caregiver is a good match for your loved one. This is a primary responsibility of the home care agency.

  2. Work with the home care agency to evaluate the safety of your loved one’s home. Pinpoint areas of risk: unsecured rugs, floor transitions from room to room, security of bars and railings, seating arrangements, access to the kitchen and bathroom.

  3. If necessary, hire home improvement contractors to add ramps, railings and other supports, widen doorways, change sink, toilet and tub configurations to improve access and safety.

  4. Consider setting up home security and remote monitoring systems that enable you to stay in touch with your loved one through video link or a phone app.

  5. Work with the caregivers the home care agency have selected to care for your loved one. Tell them about your loved one’s likes and dislikes (food, home care, entertainment, etc.).

  6. Before your loved one arrives home, arrange for the caregiver(s) to meet them at the hospital or rehab facility for a get-to-know chat.

  7. Ask for the caregiver to be present in the home when your loved one returns from hospital or rehab

  8. Make time after work or on weekends to spend time with your loved one and her caregiver. Listen to both, separately, to assess how the relationship is progressing.

Final tips

Making the transition from hospital to rehabilitation to home care can be extremely challenging, especially if the health, mobility and mental state of your loved one have changed profoundly. Through the process, remember:

  1. Make a list of questions before each meeting. There are no bad/stupid questions.

  2. Anticipate and plan the next phase in your loved one’s care long before you approach that step.

  3. Keep a notebook and record your conversations with physicians, discharge specialists, rehab experts and the home care professionals you hire.

  4. Listen to both your loved one and their caregiver to make sure they are well matched.

  5. Give yourself permission to make time for yourself – to rest and recharge. Your elderly loved one and your family will benefit.


Kevin Smith is President and COO of Best of Care, Inc. which serves Greater Boston, the South Shore, South Coast and Cape Cod communities with offices in Quincy, Raynham, New Bedford and South Dennis, Massachusetts. Best of Care’s concierge-level services include personal care services, homemakers and companions, hospice care, nursing care management and specialty services as they relate to dementia and acquired brain injury care. Best of Care Inc. was named a 2014 Family Business of the Year finalist by the Family Business Association of Massachusetts. Smith is an Executive Committee and Board Member of the Massachusetts Council for Home Care Aides.

Connect with Kevin Smith at or call (617) 773-5800 x 117.  Follow Best of Care on Twitter @BestofCare and like us on Facebook at


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