From Rehab to Home: How We Support Successful Recovery After a Health Crisis
After a medical emergency or major health setback, many older adults are discharged from the hospital to an inpatient rehabilitation center before returning home. Rehab stays offer valuable therapy and medical supervision to launch the process of recovery. Despite the help from rehab, the next step of planning the return home can feel overwhelming.
Our Aging Life Care Managers® play a vital role in helping older adults and their families navigate this transition smoothly. Whether someone is recovering from a brain aneurysm, stroke, or surgery, a care manager brings the coordination, oversight, and emotional support needed to help them regain independence and thrive at home.
The Role of Inpatient Rehab
Rehabilitation centers offer targeted therapy that helps older adults rebuild strength, regain function, and restore cognitive skills. A care manager works closely with the rehab team to monitor progress and plan the next steps. We also catch and handle any concerns that could cause bigger issues.
Typical rehab services may include:
- Physical Therapy (PT): Helps with strength, balance, and fall prevention
- Occupational Therapy (OT): Focuses on regaining skills for daily tasks like cooking, rooming, and managing the home
- Speech Therapy (ST): Supports communication and cognitive function, especially after a neurological event
While the clinical team delivers therapy, the care manager stays in touch with both the client and their family, ensuring that services are aligned with long-term goals.
Planning the Return Home
As discharge approaches, our clients often feel excited but also nervous about what comes next. A care manager takes the lead in creating a comprehensive plan that ensures safety, comfort, and flexible plan for current and future care needs.
Key elements of a safe home transition include:
- Home Safety Evaluation: Identifying and fixing hazards such as slippery flooring, poor lighting, or narrow doorways
- Modifications and Equipment: Coordinating grab bars, raised toilet seats, mobility aids, or adjustable furniture
- Follow-Up Appointments: Scheduling continued physical, occupational, or speech therapy
- Meal Planning: Supporting nutrition with meal services or connecting with specialists in dietary support for brain health or chronic illness
- Personal Care Assistance: Coordinating part-time caregivers or home health aides through trusted agencies
A care manager acts as your advocate, making sure that your wishes are followed as well as watching for overlooked details that could jeopardize recovery.
Addressing Emotional Concerns
Returning home isn’t just about logistics, it’s also an emotional adjustment. Older adults may feel anxious about managing if they are alone, or if their spouse can help them in case of urgent needs. There are many concerns surrounding the rigor of more care and even emergencies. A care manager helps clients feel empowered and protected by:
- Listening to fears and validating concerns
- Recommending tools like medical alert systems for emergency support
- Offering coaching to build confidence and independence
- Involving family in reassurance and realistic planning
- Coordinating home care services as needed
When an older adult feels emotionally supported and has a clear safety plan, they’re more likely to succeed in long-term recovery. Also, with one of our care managers assisting them they may find it easier to ask for assistance since we are hired professionals.
Reliable Ongoing Support After Discharge
Care doesn’t stop when a client returns home. We continue to check in, reassess the plan, and make changes if new needs arise, helping arrange transportation to follow-up appointments, connecting families with counseling services, helping with understanding insurance or Medicare coverage, and remaining available as a consistent, reliable partner.
Transitions from inpatient rehab to home are critical moments in an older adult’s health journey. With the help of an Aging Life Care Manager®, you and your family can move forward with confidence by knowing that safety, comfort, and emotional wellbeing are all being considered. Recovery is never one-size-fits-all, but with expert guidance and a thoughtful plan, it can lead to true independence and peace of mind.
Maria’s Aneurysm Recovery: Inpatient Rehab and Transitioning Home
Last month, we shared Maria’s journey through a ruptured aneurysm and ensuing surgery to her discharge into an acute inpatient rehab center, with her daughter Sofia and their Aging Life Care Manager® by her side. This month, we’ll see how Maria is handling rehab and the steps that are taken to bring her home.
Working Through Intensive Rehabilitation
Even though Maria was hesitant about moving to a temporary facility instead of going straight home, once she arrives at the inpatient rehab center she fully embraces therapy and works hard to regain her independence. The rehab center provides several different therapies to help Maria recover:
- Physical Therapy (PT) helps Maria regain strength, balance, and coordination to prevent falls.
- Speech Therapy (ST) addresses mild word-finding difficulties and assists in recovering cognitive focus.
- Occupational Therapy (OT) teaches Maria how to relearn fine motor skills so that she can perform daily tasks like dressing, cooking, and gardening.
The care manager monitors Maria’s progress throughout her time in rehab, ensuring that everything is being done that will help Maria get home as soon as possible. Sofia is encouraged by her mother’s progress during her visits and begins talking to the care manager about home transition plans. Sofia, Maria, and the care manager meet together with the rehab social worker, who reports on Maria’s progress to Medicare. After talking to the care manager and the therapists who have been working with Maria, the social worker brings good news: Maria can return home next week!
Preparing for Home Care
Together, the care manager and Sofia prepare Maria’s home for her return. The care manager conducts a home safety evaluation and arranges the installation of grab bars in the bathroom, no-slip flooring in the kitchen, and adds comfortable and accessible furniture to the living room. She also coordinates further therapy appointments for Maria. After talking with Sofia about the importance of nutrition in recovery, the care manager also arranges a meal service from a personal chef that is suited to brain health and overall wellness.
While Sofia is delighted that her mother is finally coming home, she is also nervous about her ability to provide the proper care for Maria’s recovery. The care manager assures Sophia that she will continue to help with Maria’s recovery after discharge and offers to connect Sofia with a trusted home care agency to bring in a part-time caregiver. Sofia agrees, thankful that the care manager was able to coordinate so many little details of the transition that might have been missed otherwise.
The Return Home
During her last week in rehab, Maria counts down the days until she can go home. In the midst of her excitement, she feels a little nervous about going back to less supervision. The unexpected nature of her aneurysm made her realize that she was more vulnerable than she had thought. What if something like that happened again and someone found her too late? The care manager noticed Maria’s nervousness and talked with her about her fears. The care manager recommended wearing a medical alert device that Maria could use to call for help in case of another emergency. Reassured, Maria left the rehab center and returned home confident in her ability to recover her independence.
Next month, we’ll see how Maria and Sofia navigate home care physically and emotionally.
Read the previous installments of Maria’s story:
Find out how Maria’s story ends!