9 Tips for Transitioning an Aging Adult Home From Rehab


Certified Care Manager, Aging Life Care Professional, and National Master Guardian Emeritus

Rehab, often called skilled nursing, is a valuable service that helps older adults recover from an accident or illness. For traditional Medicare to patient-paid rehab, the patient first spends three nights in the hospital.

Some Medicare Advantage plans will waive this requirement for someone to go to rehab. From there, the patient transitions to another type of care. For aging adults, this is usually a nursing home, group home, or aging adult home. 

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Hospital stays are getting shorter and shorter, and there is evidence to support the idea that extended stays in the hospital for older adults are not beneficial. On the other hand, a discharge to rehab may not guarantee recovery in the time allotted by insurance. Once insurance benefits run out, or progress has stalled, discharge home is inevitable. 

As a concerned family member of someone in rehab, you will want to prepare for your loved one’s transition back home. Safety, accessibility, ability to manage hygiene, and mobility are some of the issues to consider. In some cases, you won’t have much time to plan and prepare before your loved one comes home.

Things to Remember When Making the Transition from Rehab to Home

There are some crucial things to remember when an aging adult transitions from rehab to home. It may be better to over-prepare so you aren’t in a position of feeling stressed and overwhelmed by having to make decisions when your loved one gets home. 

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1. Start planning as soon as possible

Start planning as soon as your loved one is admitted to rehab. You won’t have much idea of how long the stay will be and time could be short. Although most Medicare plans can cover up to 100 days of rehab, there could be unaffordable co-pays for some of those days. 

You can make changes and anticipate safety issues before they occur by planning early. If you don’t have advance directives in place, you will want to complete those as soon as possible. To advocate for your loved one and to honor any medical wishes, you will need the legal authority to do so.

2. Your loved one may need more help than you think

Team meetings usually include rehab, nursing, and social work to review your loved one’s progress during any rehab stay. If you can, attend these meetings because they will give you more detailed information on progress, challenges, and goals. 

Assume that your loved one will need more daily help than you think. There is round-the-clock on-demand assistance in rehab with activities of daily living, nursing, and physical therapy up to 5 days a week. When someone gets back home, it is hard to replicate that level of care. 

3. Ask about home health options

When transitioning from rehab to home, having home health can provide a layer of support. The physician at rehab will need to write an order for home health so your loved one can begin as soon as possible after they return home. Ask about companies that the rehab may recommend covered by your loved one’s insurance. 

Home health is not as frequent or robust as rehab, but it can significantly help. Physical and occupational therapy are generally available about three days a week, and home health aides can help your loved one with bathing, hygiene, and transfers. Although home health is also short-term care, it can help ensure a safer transition from rehab to home. 

4. Consider home accessibility

A thorough review of your loved one’s home is a necessary step before they transition from rehab. Home safety and accessibility additions and changes depend on your loved one’s functional condition when they return home. Some considerations include:

  • Stairs: Stairs can be a fall risk if the home is structured where the bathroom and or laundry room require a flight of stairs. If your loved one has mobility issues, using stairs could be a problem. If your loved one returns home in a wheelchair, do they need a ramp to enter the home safely? Are the doorways wide enough for ease of movement?
  • Bathrooms: Many older homes have step-in tubs with showers. Your loved one may be unable to navigate a step-in shower safely.  You may need to consider a walk-in shower,  grab bars, a toilet riser with handles, etc.
  • Kitchen: Using a kitchen is something most of us do routinely. Your loved one may return from rehab and be unable to reach counters or use the stove safely. How will they prepare meals?
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5. You may need home care workers

Home care is different from home health. Home care workers are privately paid caregivers who usually work for private companies. In most states, home care caregivers are limited by state rules to helping with activities of daily living, companionship, cooking, transportation, and shopping. 

Home health aides are not permitted under Medicare rules to cook, provide transportation, or shop. This is why home care could be a valuable addition to your loved one’s care. When home health discharges your loved one, there could still be significant areas where they need assistance.

6. Purchase an Emergency Response System (ERS)

Next, an emergency response system is a pendant or watch that detects falls and calls emergency responders. Unless someone is with your loved one 24/7, an ERS is advisable. Some ERS have GPS locators for people who wander. 

These are more affordable than you think, and this can be part of your family’s emergency plan. 

7. Consider assisted living options

When thinking about a transition from rehab to home, some families start thinking about the advantages of assisted living. If your loved one struggles with functional activities, piecing together enough care can be cumbersome and expensive. 

Luckily, assisted living eliminates many of the challenges of coming home. For example, assisted living is handicap accessible and provides meals and transportation. A nurse dispenses medications, and aides are available for bathing and hygiene. You can also arrange for home health in assisted living.

8. Be flexible with your solution

You and your loved one hope for a speedy and complete recovery and return to independence. But this does not always happen. Whatever solid plans you have put in place may need to change. Be as flexible as you can in adjusting the care to meet your loved one’s needs.

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9. Ask for family support

Lastly, you don’t have to make this transition from rehab to home alone. Reach out to siblings and other family members for their support and help. 

If you need help in the first few days after your loved one returns home, ask for it. The initial return home can be chaotic and stressful, and you may need all the help you can get.

Who Can Help With Issues When Transitioning Home From Rehab?

You are not alone when dealing with issues of transitioning your loved one home from rehab. There is expert help available to assist you with navigating decisions and planning for the future. Rely on these professionals for assistance.

Rehab social worker

Every rehab community will have a social worker to assist with discharge planning. The social worker will have experience in what level of care your loved one will require when they return home. 

Since the social worker is part of the rehab team, they can assess your loved one’s needs for a return home.  They will also have recommendations for home health and home care companies. If you are considering assisted living, they could have suggestions.

Geriatric care manager

A geriatric care manager is a social worker or a nurse who specializes in assisting families with decisions regarding care. An experienced geriatric care manager will have had many years of experience helping families transition from rehab to home. 

Additionally, they can evaluate your loved one and their home situatuion to develop a list of needs, goals, and plans for a safe transfer home. Geriatric care managers are generally private pay, but if your needs are not ongoing, paying for consultation can be well worth it.

Physician nurse case manager

Your loved one may be lucky enough to have a geriatric physician with a nurse case manager on staff. More and more clinics are using nurse case managers as part of their practice to assist patients transitioning from the hospital to rehab and from rehab to home. Ask your loved one’s physician if they have a nurse case manager who can help.

Local agency on aging

Your local aging services can be a good resource for programs and other support services when your loved one returns home. They can help you find respite care, meals on wheels, and senior transportation.

Senior care placement specialist

If you are considering assisted living for your loved one, a senior care placement specialist is a person who helps families find senior living communities. These professionals have a breadth of knowledge about the local assisted living options and can help you choose one within your budget and with the services that your loved one needs. 

Even if you don’t select an assisted living facility now, knowing your choices and identifying two or three will give you some confidence if you need to make a decision later.

The Transition from Rehab to Home

A successful transition from rehab to home is possible with enough planning. A complete understanding of the resources available will make your loved one’s transition back home safe and affordable.

Navigating these next steps can be intimidating, especially if you’re not familiar with your resources. It’s okay to take your time when helping your loved one through this life transition. 


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