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Out of the Hospital But Not Ready for Home: Closing the Gap

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If you or your loved one has been discharged from the hospital, ensuring a continued high level of care is key to regaining health, strength, and mobility. Short-term rehabilitation, or “rehab,” centers provide medical follow-up for patients in their first days after a hospital stay – and can mean the difference between a stressful rebound to the hospital and a seamless return to home.

Delivering continuous care

With today’s focus on cost containment, many patients are being discharged from the hospital faster, often before full recovery. Their medical problem has been addressed, but they’re still vulnerable.     

“When patients go home too early, they may quickly decline and end up back in the hospital,” says Teresa Dowden at Briarcliff Skilled Nursing Center, a leader in senior care. They may be in a weakened state, may be taking numerous medications, and may be managing several chronic conditions. Without medical supervision, a minor problem can readily escalate into a mammoth one.”

A rehabilitation center provides 24×7 access to team-based care. Comprehensive rehab services can close the care gap, increasing your prospects for accelerated healing – and decreasing the chances you’ll return to the hospital. Your recovery will be monitored by a collaborative team, who will coordinate care, oversee medications and pain management, provide a broad range of therapies and nutrition guidance, and coach you in regaining maximum function.  

Determining patient needs

Whatever the level of care needed, the key to moving forward is engaging patients in all aspects of their recovery. At Briarcliff Skilled Nursing Center for example, care teams meet with patients and their family members to address the questions and issues affecting the healing process.

“We assess patient goals and challenges, along with the estimated length of stay and range of therapies needed, from physical, occupational, and speech to respiratory and intravenous,” Teresa Dowden says. “We make sure the patient and their family understand the treatment plan so that expectations are in sync and the best choices can be made for rehabilitation.”

Early detection and intervention are critical to mitigating or minimizing complications. “It’s a comfort to patients and their families to know a team with specialized training is watching the patient continuously, as opposed to once a day in a brief home visit,”
Teresa Dowden says.

Deciding on the right facility

A strong and rapid recovery hinges on selecting the right rehabilitation center. The federal government has developed five-star quality ratings to help consumers compare senior care facilities. Beyond assessing a rehabilitation community’s quality ratings, patients and their families need to do their own due diligence.

Here are five tips for selecting the right rehab provider:

  • Check the rehab center’s track record. Review such factors as patient acuity level, staffing patterns, staff training programs, types of care plans, range of therapies, patient activities, and overall history of getting patients home without incident.
  • Find out the provider’s specialty areas. Make sure that the rehab care team is highly experienced in treating whatever illness, injury, or medical condition your loved one is living with, for example, specializes in helping patients recover from a variety of conditions, from stroke to joint replacements.
  • Assess the rehab care team’s approach to care. Do staff respect patient preferences? How do they share information and involve the family in the rehabilitation process? How are patients educated about their condition and potential complications? How are they evaluated to determine readiness to return home or to a supported living site?
  • Tour the community. Talk to staff, residents, and family. Are staff knowledgeable and empathic? Is the facility clean and inviting? Are patient rooms comfortable? Are residents engaged in activities? Are they enjoying meals?
  • Consider location. Is the rehab center close enough so that family, friends, and the patient’s personal doctor can visit?

“Make sure staff are laser focused on restoring patients to health and independence,” Teresa Dowden says. “Look for a wellness approach that addresses the needs of the whole person – physical, emotional, social, intellectual, vocational, and spiritual –providing not only vigilant care but also vigorous motivation to resume a normal life.”

If you are looking for rehabilitation and care options after a hospital stay, please visit our StoneGate Senior Living “Find a Community” page to locate a community near you.

StoneGate Senior Living provides support services in all areas of senior housing and long-term care, including rehabilitation hospitals, skilled nursing, assisted living and memory care in Colorado, Oklahoma and Texas.

Categories: Rehabilitation, Senior CareBy Marketing AssistantMarch 6, 2019
Tags: RehabRehab CentersRehabilitationRehabilitation CenterSenior care

Author: Marketing Assistant

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Briarcliff Skilled Nursing Center, Carthage
4054 NW Loop
Carthage, TX 75633
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