I’ve seen so many social media posts lately asking about what to do with their loved one who is in the hospital and really should not return to their own home. The first step should be to contact the Case Manager (CM) or discharge planner, as we called them in the “Olden Days.” If you don’t know who that is, ask the nurse taking care of your loved one. S/he can arrange for the CM to contact you. Then you can begin discussing options and short and long term plans for your loved one.
Is Rehab Care an option?
Possibilities may include some rehab time in a skilled nursing facility where they will get nursing care along with daily physical and perhaps occupational therapy to follow up from the hospital plan. Speech therapy is another rehab service that your loved one might require in the event of a stroke or other speech or swallowing disruption. The attending physician must order this, your loved one must meet certain criteria such as having real rehab potential. Be prepared for resistance because your loved one “just wants to go home.” Discuss the benefits to them and to you and investigate your options.
Medicare will pay up to 100 days per calendar year for rehab stay after a qualifying 3 day hospitalization. This is typically for patients who have suffered an injury with or without fractures, a stroke, surgical interventions, and/or de-conditioning due to a hospital stay for an illness such as COVID or pneumonia. Eligibility requirements must be met. The rehab only continues if your loved one makes measurable progress towards goals.
Another CM will follow your loved one through the rehab process at the facility. This is usually the social worker or other designated person at the facility. Ask who will be assisting with review of your loved one’s case. Be sure to meet with them at admission and discuss your goals, concerns and needs so they can be assessed and worked on while your loved one is in the facility and not the day before, or of, discharge!
Home Health Care Option
Another option is to take your loved one home either to your home or to their own home with a caregiver. The CM should have helped and advised you to find, and hire said caregiver. Or you or a friend or relative may choose to be the caregiver at least for the time being.
In addition, your loved one’s primary physician should order home health care visits from a nurse and any necessary therapists to evaluate the living situation, home safety issues, instruct in medications, provide any nursing care such as wound care, and therapists will provide a home exercise program for rehabilitation purposes.
Home health agencies may also offer services from a home health aide for personal care and hygiene, and a social worker for assistance with short and long term care planning. Understand first and foremost that the home health care professionals do not substitute for caregivers. Home health care is not a caregiving solution. Custodial care is not covered by Medicare or insurances.
These services are intermittent visits from nurses, therapists, aide, or social workers. Medicare and private insurances cover the service. There may be a copayment as well as limitations as set by the insurance carrier. The primary requirement is for your loved one to require SKILLED care from a licensed healthcare provider (nurse or therapist) and make measurable gains towards goals. If the skilled care need ends or patient meets goals, or stops making progress, the home health care will be discontinued. It’s not designed to be a long term process or solution. The main goal of home health care is to teach the patient and caregiver how to provide the care necessary and discharge.
The nurses, therapists and aides will make visits that typically last 30-60 minutes and are usually spaced 1-3 times a week, depending on the skill and needs. As a home health nurse, many times I found patients expecting me to be a companion or a personal caregiver when I arrived. I was greeted with expectations and assignments such as washing dishes, washing out underwear, or vacuuming. Indeed, these were needs, but they don’t require the education and skill of an RN to perform. While I usually tried my best to help that one time, not every nurse will do this, and it is not to be expected!
Role of the Home Health Nurse
The role of the home health nurse is to be the eyes and ears for the physician, to assess the home situation for safety and whether it meets the level of care the patient requires. The RN will assess vital signs including any pain or other signs or symptoms, discuss nutrition, assess hygiene needs, and medication compliance and understanding. If the patient requires and specific treatments such as wound care, the nurse will perform and instruct the patient and/or any willing and able caregiver in how to perform and what to report to the MD. The nurse will report to the physician and discuss any additional care needed such as Physical. Occupational or Speech/Language therapy and a home health aide or social worker. The nurse and the patient and family will work together to establish a plan of care and work together to achieve goals to make the patient as independent as possible with the best possible quality of life.
