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I get a lot of calls from families who have a loved one who are at a nursing home or hospital and are preparing to go home.  There really is a lot to consider when a person has had a crisis or illness at home that has resulted in a stay at some type of facility.  Unfortunately our healthcare system is fragmented and often connections are not made prior to the transition home, which can leave a person or family scared, stressed and questioning whether they made the right decision to go home.  


If you are leaving a hospital, it is usually after just a short stay.  Often people are trying to decide if they should go home or to a rehab facility for a short term rehab stay.  Typically if you have been in the hospital for 3 nights, you could qualify for Medicare to cover a short term rehab stay before returning home.  This is a good choice if you are extremely weak, have a lot of nursing needs and don’t really have someone at home to care for you and your needs.  


Often the consideration of going home and having home health care isn’t really explored or it is mentioned and people think they are feeling better and don’t really need this.  Home health care is crucial to returning home after most hospital stays.  Nurses can monitor your condition, work with your doctor if there are any changes, answer your questions, train caregivers, fill med planners and order prescriptions. They can also educate you and your caregivers on a new condition and what to look for to avoid another crisis.  


Therapy can work on strength and balance issues but also work on safety doing day to day activities in your home setting and can make recommendations on things to change in your home to make you more successful there.  


A social worker can assess your needs and make connections to other services and support that can help you remain independent in your home.  


A bath aide can provide support and supervision during your shower or bath to ensure an accident doesn’t happen until your strength is back.   


If you are choosing to go to a rehab facility before returning home, you first need to figure out what facility is right for you.  I recommend checking out your local facilities before you ever need them.  That way you aren’t trying to figure this out while not feeling well and already overwhelmed with your recent experience.  Understand that once you meet your goals with therapy, Medicare no longer covers this stay so you are not guaranteed any certain amount of days covered by Medicare.  The facility should be communicating this to you when you are getting close to meeting goals.  Once you are a couple days away from going home, you should have a home visit with their therapy department to see how you do in your home setting and hear their recommendations for any equipment or support you may need.  This is also where you let them know you may benefit from home health care.  They can work on the doctor’s orders and the referral to your home health agency.  


It doesn’t matter if you have met goals at the facility, you still can have home health care in most cases.  Home health helps you transition back into your home setting with support and services that can help you avoid a setback.  It is better to have too much help at first and back it off rather than get home, need help and not be able to get it right away.


When you are in a facility, they are handling everything for you like your medication management, helping with your shower, appointments and transportation, etc.  It can be overwhelming taking all that responsibility back on without some support.  Remember it doesn’t have to be long term help in the home, but the goal is to keep you at home without a set-back that could have been avoided.  Supportive services not covered by Medicare are also an option and very important.  These services help with your day to day needs like laundry, housework, meal prep, grocery shopping and errands, etc.  These services often take a week or two to get scheduled so it is better to have them in place prior to going home.


If you or someone you know is preparing to return home after a hospitalization or rehab stay/nursing home stay, please call us for help coordinating services, 800-228-5993.  Western Illinois Home Health Care is a full service provider providing both Medicare covered services and supportive services.  Our senior care manager can help you weigh your options and arrange services for when you return home.  


Amanda Powell, BSW is a Senior Care Manager for Western Illinois Home Health Care


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Transitions From Hospital and/or Nursing Homes Back Home

February 2016

by Amanda Powell