Next Step in Care: Family Caregivers & Health Care Professionals Working Together

Hospital to Inpatient Rehabilitation

About the Transition


Sometimes after a hospital stay patients may need additional time to recover before they can go back home. For example, patients who have suffered unanticipated events—strokes, fractures, traumatic brain injuries, or heart attacks–or scheduled surgeries like hip replacement–may be referred for rehabilitation or “rehab” services, where they can receive therapy to help them get stronger, to try to regain abilities they may have lost, or to help maintain function. Rehabilitation services are provided in various settings, such as skilled nursing facilities (SNF), inpatient rehabilitation facilities, nursing homes, rehab units within hospitals, and other specialized settings.

Many family caregivers and patients are unfamiliar with rehab, but as a family caregiver you are an important member of your family member’s care team. Often when patients are discharged from hospital to rehabilitation, most of the communication occurs between the hospital and the rehabilitation services medical team, yet it is important that you understand your family member’s options and plan of care. Once you are informed that the next step might be rehab, we recommend you read our guide “Short-Term Rehab Services in an Inpatient Setting”. This will provide you with an overview of rehab options and the rehab process.

Even though the hospital will be sending your family member’s medical information and medication regimen to the rehab facility, we recommend that you ask the medical team to help you complete a Medication Management Form with the list of medication you family member will need. You can then use it to compare with the medications provided once at the rehab facility.

While your family member was hospitalized you had probably received information about HIPAA. It’s a good idea to review it. While all rehab facilities are required to follow HIPAA rules on sharing information, each facility has its own privacy rules and requirements. It is important that you understand your rights under the HIPPA law. Our guide, HIPAA: Questions and Answers for Family Caregivers, can help you with that.

If your family member does not have any form of advance directives, such as a health care proxy, it is important that one be completed. The guide to Advance Directives can help you in the process.

While it might be difficult to think about discharge at an early point in the rehabilitation process, it is important to start planning for it as soon as possible. Our guide on Short Term Rehab Services in an Inpatient Setting will provide you information about the discharge process from rehab.
What Do I Need as a Family Caregiver?
can help you assess and understand what supports or training you will need in order to help your family member after discharge from rehab; and Going Home: What You Need to Know is a simple checklist that can help you get organized. It is a place to note the various tasks and supplies you will need to help your family member at home. We recommend that you review and complete the checklist with a member of the medical team before discharge from rehab.

A guide to Medication Management will help you understand the process of medication reconciliation so that you know how to manage your family member’s medications, and can prepare for any changes in medications following discharge. We also recommend that you update the list of your family member’s medications before discharge. The Medication Management Form can help with that important task.
If your family member is referred for home health care services following discharge, or if you decided to privately hire a home care agency, we recommend that you review Home Care: A Family Caregiver's Guide.

Finally, we recommend that you read about Emergency Room (ER) Visits to help you limit these visits following discharge and help you understand the way care is provided in this setting.

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