Hospital to Rehab Facility

Sometimes after a hospital stay patients may need additional time to recover before they can go back home. For example, patients who have suffered unanticipated events—strokes, fractures, traumatic brain injuries, or heart attacks—or scheduled surgeries like hip replacement may be referred to a rehabilitation or rehab unit, where they can receive therapy to help them get stronger and try to regain abilities they may have lost. Rehabilitation can be appropriate for others as well. Rehabilitation services are provided in various settings, such as nursing homes, rehab units within hospitals and other specialized settings.

As a family caregiver you are an important member of your family member’s medical team. Although often when patients are discharged from hospital to rehabilitation most of the communication occurs between the hospital and the rehabilitation medical team, it is important that you understand your family member’s options and plan of care. Many family caregivers and patients are unfamiliar with rehab. Once you are informed that the next step might be rehab, we recommend you read about Planning for Inpatient Rehabilitation Services. This will provide you with an overview of rehab option and the rehab process.

Even though the hospital will be sending your family member’s medical information and medication regimen to the rehab facility, we recommend that you ask the medical team to help you complete a Medication Management Form with the list of medication you family member will need. You can then use it to compare with the medications provided once at the rehab facility.

While your family member was hospitalized you had probably received information about HIPAA. It’s a good idea to review it. While all rehab facilities are required to follow HIPAA rules on sharing information, each facility has its own privacy rules and requirements. It is important that your understand your rights under the HIPPA law. Our guide, HIPAA: Questions and Answers for Family Caregivers, can help you with that.

If your family member does not have any form of Advance Directive, it is important that one be completed. The guide to Advance Directives can help you in the process.

While it might be difficult to think about discharge at an early point in the rehabilitation process, it is important to start planning for it as soon as possible. Going Home after Rehab will provide you information about the discharge process from rehab. What Do I Need as a Family Caregiver? is a form that can help you understand what you will need in order to help your family member after this discharge. A guide to Medication Management will help you understand the process of medication reconciliation so that you know and prepare for any changes in medications following discharge. Going Home: What You Need to Know is a simple checklist that organizes the various tasks and supplies you will need. We recommend that you review and complete this form with a member of the medical team before discharge. Since medications can sometimes change during the rehabilitation period, we recommend that you update the Medication Management Form before discharge.

If your family member is referred for home care services following discharge, or if you decided to privately hire a home care agency, we recommend that you review Home Care: A Family Caregiver's Guide.

Finally, we recommend that you read about  Emergency Room (ER) Visits to help you limit these visits following discharge and help you understand the way care is provided in this setting.