Hi, my name is Jami. I’m a care advisor at Ways & Wane, and I’m also a master’s level social worker. I wanted to share some information and tips about navigating when an older adult is discharging from a facility rehab stay.
Three things to be mindful of before discharge from rehab are medical equipment, medications, and discharge questions.
The discharge disposition is where you want to understand what the older adult will need once they return home, wherever their home is, whether that be home to a facility, home with family, or their private residence.
Things that they might need or have been recommended by the staff could include home health or physical therapy. You would want to know if they already sent over a referral for services and if there’s anything you need to do to make sure that they receive this continuation of care.
Do they need in-home caregivers? If so, what kind of help is needed? Do they need help with bathing, meal preparation, or getting in and out of a seated position?
Medications are important to consider because if it is a new medication, there’s always the possibility that the medication might not be covered by the insurance company. The preferred pharmacy may not currently have that medication in stock or may not routinely carry it, so requests will need to be submitted before the person discharges from their rehab stay.
Is there someone, or the patient themselves, who understands what the new medication is for? How often it should be taken, how to administer it, and are there any side effects that need to be watched for?
For medical equipment, similar to medications, you’ll want to know if it’s covered by insurance, where it’s coming from, and whether the equipment will be available prior to the older adult discharging. Are there any items being recommended that aren’t covered by insurance but would help improve quality of life, independence, or mobility?
In addition, think about the next appointments. Are there any follow-up appointments needed with the primary care physician or specialists? Are there tests such as labs or imaging? If so, have those appointments been set up, or is there something that you or your older adult need to do?
If home health was ordered, do you know when services are going to start?
I also recommend the GoKit medical planner, which includes a section for discharge planning.
If you disagree with the discharge, know that you have rights. There is an appeal process, and you should be served with a document called a Notice of Medicare Non-Coverage, or NOMNOC. This must be provided at least 48 hours before the last day of service.
I hope you find joy in loving one another well.
