Transferred To Rehab By Jean Oswald
Starting with the possible need for your loved one to transfer to a rehab unit in the community, here are a few things to know before that decision is made:
1. Staying in touch with the discharge planner (as I mentioned in Part 1) about the medical team's plans for treatment and anticipated discharge will help you and your loved one make plans, communicate with healthcare providers and avoid at least some of the surprises that come with hospitalizations.
2. As you know, bloodwork is often drawn daily on hospital patients, and this is where things can start to happen very fast. For example, test results at 8 or 9 a.m. might look really good to the doctors, so to them, it appears that your person is now "well" enough to go home! But this could easily surprise you if you're unaware of lab results. You might feel unprepared, but this is one of the things that can happen, so go look for the nurse taking care of your person to understand what is proposed for discharge.
3. IF it seems clear that your person needs some physical therapy before going home, it might be possible to get it for a day or two while they are inpatient. If that's possible, see if you can find out when PT will be coming because you would "like to learn" how their treatments and exercises get your person back to their independent self (or as close to it as possible). This time with PT might also alert you to a need for Occupational Therapy (OT) if that comes up.
4. Depending on the hospital's census, and your person's level of mobility, it might be necessary to have your person go to a rehab facility to finish their PT. Sometimes there is added pressure when a discharge planner tells you that your person will be required to pay for the additional days "out-of-pocket" if they remain in the hospital because "insurance won't cover any more inpatient days." If this happens, the discharge planner should have given you a list of 4-6 facilities that have rehab units for you to consider. You could be asked to give your 1st and 2nd preferred choices from that list. Just know that when you give your top choice(s), there may not be an available bed at that facility.
5. If your person is feeling added pressure to be discharged, find the Social Worker or go to "Patient Relations" in the hospital and tell them you're struggling. Say that you want to help your loved one get a "safe discharge" to home. Hopefully you can report that you've looked at one or two rehab facilities, but want to visit "one or two more."
6. What if your person can't stand on their own (i.e. they're "non-weight-bearing")? There might be a pre-determined amount of time that rehab is covered by insurance and if that is not enough, your loved one might need to remain in a skilled nursing facility (SNF) long-term. That is another reason to go check out potential rehab units, remembering those units are not like the regular floors.
7. The hospital's nurse case manager or discharge planner should make sure the rehab staff knows about your loved one's treatments, medications, and anything else important for your person's continuing care. The case manager at rehab should be able to confirm with you that they received that information as well.
Rehabilitation
Things to know for your loved one in Rehab:
1. Think about those special items or requests you will have for your person in rehab. It might be a special cup that doesn't tip over, a pair of slippers or shoes that won't slip. Bring them, but send valuables and cash home. If your loved one needs their food cut up, you may need to ask a few different people (nurse, aide, supervisor) to do this so that your person doesn't choke and actually eats! Know that you might need to have the same conversation more than once.
2. Once your person is in rehab, a "plan of care" is set up for them within 48 hours of admission by the medical team there. Tell the Nurse Case Manager or Director that you're very involved in your person's care (if it's true) and ask if you can be present for the meeting to hear their plan, or, at the very least, have a meeting afterwards to understand how goals will be met. Then communicate with staff regularly to monitor progress and their personal care.
3. "Recertification" as well as Insurance coverage determines how much time your person can stay in rehab. Most patients who've received rehab are consistent in reporting a positive experience there, but it's wisest for you both to participate in family meetings and stay abreast of how the goals of care get fulfilled. Stay in touch with the case manager or discharge planner. Remember: polite assertiveness and showing you want to support those goals will keep communication active and decrease the unwanted surprises.
4. If your loved one needs to stay in a SNF or "Skilled Nursing Facility" (probably the same facility where rehab took place) it will be important for your person to have extra support. Staff shortages, especially since the exodus of healthcare workers during and after Covid, has brought change to nursing homes. It is now just a fact of life that everyone needs to accept and work with. This involves having a lot more patience with nurses and aides who have remained in place and doing the best you can to attend family meetings (monthly or every 6 weeks if they're still held that often). Do what you can to offer more physical help yourself as well. I also suggest thanking the staff for what they're doing each day.
This was Part 2 in the series “How to Advocate for Your Loved One when they need Hospitalization.” Stay tuned for the next article - tips on the “Preparations for Your Loved One returning Home.”
About Jean Oswald: Jean’s nursing career spans more than three decades in the hospital and community settings, but it is end-of-life work that is most aligned with her Soul’s purpose. Jean offers practical, real-time advice to clients with a serious illness who are nearing end-of-life. Jean is a valuable resource for our aging population, recently publishing a book titled Guiding Lights: Navigating the End-of-Life Journeywhich can be purchased at Amazon.
Jean's Website: https://compassionateconsulting.com/
Find her book on Amazon: https://www.amazon.com/dp/B0CP6GT3X1?ref_=cm_sw_r_cp_ud_dp_PK9BZ8K0SRK6B208SW6F
