Understanding the Types of Nursing Facility Stays
Nursing facility stays typically fall into two categories:
- Short-Term Rehab: Often following a hospital stay, these patients are in recovery and require physical therapy, occupational therapy, or other rehabilitation services. The goal is to help them regain strength and independence to return home.
- Long-Term Care: For individuals requiring ongoing assistance, long-term care focuses on daily living needs, rather than intensive rehabilitation. Families may decide to bring a loved one home from long-term care to receive private, in-home support, particularly if they feel their loved one is not thriving in the facility.
Partnering on a Path to the Best Possible Outcome
Regardless of the need to move a loved one or the urgency it might entail, our team carefully executes a care plan that works closely with and for the family…and leaves no stone unturned to reach the best possible destination for each unique individual.
1. Meeting with the Facility’s Discharge Team
Most nursing facilities have a discharge team responsible for creating a transition plan for patients heading home. This team often includes social workers, therapists and discharge planners. To ensure a smooth transition, we work with families to meet with the discharge team to discuss the level of care their loved one will need at home.
Some key points to cover in this meeting include:
- Current Care Needs: Physical, occupational, or speech therapy requirements.
- Necessary Equipment: Items like hospital beds, walkers, or lifts, which may need to be arranged through Medicare.
- Medical and Daily Care: Nursing needs, medication management, and assistance with activities of daily living (ADLs), such as bathing, dressing, and meal preparation.
We work with families to stay in close contact with this team, especially to confirm that any needed equipment is delivered to the home before discharge. Coordination and collaboration with the discharge team is critical in making the transition home a smooth and successful one.
We don’t expect families to have the experience and know-how when it comes to thinking of everything and making sure nothing is overlooked, so we like to step in and step up to make sure all of the details are addressed and accounted for.
2. Arranging Home Care Support
A loved one returning from a nursing facility often requires consistent in-home care. Our home care experts work closely with family members and discharge teams to create a customized care plan for each unique individual. This plan can include hourly or live-in caregivers who handle tasks such as:
- Personal hygiene and grooming
- Meal preparation and dietary monitoring
- Mobility assistance and exercise support
- Household support such as laundry and light cleaning
- Medication reminders
- Companionship and emotional support
In addition to personal care, many people qualify for short-term skilled nursing or physical therapy services at home through Medicare. These services complement non-medical home care and vice versa. Together, the skilled nursing team and the ADL caregivers provide the optimal team to enhance recovery by providing medical support and daily living assistance at once.
3. Home Environment Assessment
It’s essential to assess the home environment to ensure it meets the returning loved one’s needs. Our professional care providers will insist on conducting home visits prior to patient discharge to identify necessary adjustments that may be required.
Again, we’re looking for things guided by years of experience, and we have particular expertise in evaluating each home, each family and each individual as the unique situation that they represent. The family is unlikely to share that depth of knowledge, and the discharge staff likely won’t visit the home. We fit in as the natural and capable conduit between the family/patient and the facility they are transitioning home from.
Typical assessments we make include:
- Bathroom Modifications: Are there bath bars, shower chairs, and hand-held shower heads onsite to make bathing safer?
- Stair Accessibility: For multi-level homes, should the family consider setting up a living space on the main floor, especially if mobility is a concern? If the shower is on the second floor of a two-story home, it may make first-floor living challenging for many.
- Accessibility Aids: What may need to be installed or brought into the home to make daily living safe and comfortable? Walkers, lifts, or other mobility aids can be essential, depending on the home layout.
- In-Home Living Quarters: Will the person require that someone move into the home to provide hands-on observation and care? If so, might the home need to be organized or updated to accommodate this new occupant in the home?
These assessments and advanced preparations help create a supportive environment that fosters safety and ease of movement. Our team can foresee what needs may exist in the current situation, as well as those that may present over time. So be sure to have an expert visit the home before discharge occurs.
4. Exploring Financial Assistance Options
Families often face financial concerns when bringing a loved one home. Although Medicare may cover short-term rehabilitation needs from skilled nursing professionals such as physical and occupational therapists, extended home care is typically paid privately unless the individual qualifies for state programs like Money Follows the Person (MFP) or Veterans Affairs (VA) benefits. Long term care insurance policies are also a payment option.
As we outlined here, we are eager to work with families — and even on their behalf — to identify and pursue payment programs and qualified benefit plans that the family might not otherwise consider or know that they are eligible for.
5. Building a Long-Term Care Plan
Bringing a loved one home is often a starting point, and planning for long-term care is a wise consideration. Elder care attorneys and geriatric care managers can help families develop a plan to access additional resources and manage financial matters that come with caring for an elderly loved one. Though we do not provide these services directly to families, we have, over the years, built a deep and broad network of ancillary service providers who serve the family in ways that are complementary to the care we provide.
We are happy to not only refer our families to such trusted and vetted resources, but we work well when serving at the center of a complete program and team of care and advisory services for our seniors and their families. We often find ourselves in the welcome position of chief coordinator of, not only our own suite of services, but the related professionals who serve the families in our care holistically.
6. Creating the Roadmap and Guiding the Path
For most of the families who contact us for the first time, one of the most comforting things we provide is the roadmap. With so many questions and concerns all facing the family at the same time — when most is at stake emotionally, financially and logistically — our entire team thrives on being the collaborators who can partner with families to design the proper pathway forward. We have the decades of experience to know where the challenges are, where the opportunities might be hidden from plain sight, and how to chart a course for success, safety and satisfaction.
Once the roadmap is designed and agreed upon, we work with families to navigate their loved ones toward the destination of their choosing, removing as many bumps as possible along the way.
Back Home. Back to Business.
Bringing a loved one home from a nursing facility requires careful planning and resources. But with the right support, you can feel confident that your loved one’s return will be as smooth and successful as possible. Working with experienced professionals, assessing the home, and preparing for ongoing care can make a world of difference.
From the moment someone calls Assisted Living Home Care Services, he or she is no longer alone. He or she is no longer overwhelmed and desperate, but rather, at peace…educated… confident…calm. For it is at that moment that the family caretaker becomes part of a skilled, dedicated, compassionate, and highly capable team.
No matter the individual need of each unique family or loved one, our mission is to allow seniors to continue living the fulfilling lives they deserve with dignity — while giving the family’s life, time and hope back.
