Leaving the hospital

MetroWest CARES, the Committee Addressing Resources for Eldercare Services, is coordinated by United Jewish Communities with support from the Healthcare Foundation of New Jersey; CARES brings together professionals and lay leaders from MetroWest agencies that provide services to older adults. Each month, a MetroWest CARES agency presents an educational column on an eldercare issue; this month’s article is presented by Lisa Verdon, director of Social Services at Daughters of Israel. Daughters of Israel recently opened a state-of-the-art sub-acute rehabilitation facility with rehab provided by Select Medical Rehabilitation Services, an affiliate of the Kessler Institute for Rehabilitation. The new facility features a state-of-the-art rehab gym with Nautilus Next Generation equipment, a transfer training car and therapeutic kitchen, in addition to recovery suites with luxury amenities.

After a hospital stay of more than three days as a result of an incident such as a fall, broken hip, stroke, or infection, a patient can be admitted to a sub-acute rehabilitation facility for physical therapy, occupational therapy, speech therapy, skilled nursing care, and/or any combination of these services.

There are three main payment sources for sub-acute care: Medicare Part A, private insurance (managed care), and secondary private insurances or Medicaid (for copayments). Medicare pays for up to 100 days in a sub-acute rehab facility. The first 20 days are covered at 100 percent. After the 20th day, Medicare covers 80 percent. Patients are left with a 20 percent copayment that can be covered by a secondary insurance. Otherwise, patients will be billed for the 20 percent.

Upon admission to a sub-acute rehabilitation facility, many assessments are done by the Interdisciplinary Care Plan team, which typically includes a rehabilitation therapist, registered nurse, physician, social worker, dietician, and an activities coordinator. Within a week, the social worker sets up an initial family meeting to discuss assessments, progress, goals, and plans for discharge. This first meeting also gives the family an opportunity to ask questions and address any concerns they may have.

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Patients are put onto a rehabilitation schedule, usually five or six days per week, and their progress is monitored by the IDCP team. Once the patient is ready to return home, and a discharge date established, the social worker works closely with the rehabilitation department and family to plan a safe transition home.

Clients and their families often feel anxiety about the return home. Many rehabilitation patients grow accustomed to round-the-clock support and care. To ease the transition, social workers work on reinforcing the significant improvements and progress the patient has made since their first day in the rehabilitation facility. Part of easing the anxiety is building up the patient’s confidence. However, confidence building is not enough. Another aspect of the discharge planning process is arranging for the physical care that will be required at home.

For example, one client was recently discharged after receiving rehabilitation therapy for a fractured hip. As expected, she was anxious about returning home. The social worker managing the case tried to reassure her as much as possible, emphasizing her tremendous progress as evidenced by the fact that the client was now able to use a rolling walker. The social worker also contacted a visiting nurse service to arrange for a home health aide, physical therapist, and occupational therapist at home. The visiting nurse service came to the rehabilitation center to evaluate the client’s need so that the right supports would be in place when she returned home. In addition, a follow-up evaluation in-home was scheduled before she left the facility. The rehabilitation department ordered the medical equipment she needed, including a commode and a rolling walker, so that they were ready for her when she returned home.

The social worker assists in coordinating visiting nurse services, rehabilitation at home, private home care, Meals on Wheels, Medicaid programs, and other necessary community referrals. In addition to a visiting nurse service, the rehabilitation department can do a home evaluation to assess for safety hazards and the need for any adaptive medical equipment such as grab bars for the shower, chair lifts, and wheelchair ramps.

Once the discharge plan is in place, the social worker informs all appropriate departments, and requests prescriptions and discharge orders from the physician. On the day of discharge, patients are often picked up by family members or transported by a private transportation company.

The discharge planning process can be challenging for the client leaving the comfort of a rehabilitation facility. However, it’s the responsibility of our team to ensure that this transition is done smoothly, by addressing the physical and emotional concerns of the residents and their families to ensure a safe return home.

Families and caregivers needing answers to broader eldercare questions and help with community resources can contact Elderlink – a portal to all MetroWest services for older adults and their families. Elderlink can be reached at 973-765-9050, or via e-mail at elderlink@jfsmetrowest.org.