Transitioning Home from Rehab and Recovery

Author: Maine Veterans' Homes
Posted: June 21, 2017
Category: Rehabilitation & Therapy

A short-term stay in a nursing home is both valuable and often a necessity when a loved one is recovering from a surgery, stroke or other serious illness. With 24/7 specialized care, they gain strength back in a safe environment.

Then the news comes that it’s time for your loved one to come home! This is both a celebration and often worrisome for family members. As the caregiver, you begin to wonder: Will the transition from rehab to home be smooth? What do we need at home to ensure recovery continues? What do I need to know?

Transitioning from Skilled Care to Home Confidently

Even after getting all your questions answered, we have found that most people do not realize the full scope of what recovery will be like at home.

“There are a lot of moving parts that many people often don’t realize,” says Michelle Bell, rehabilitation manager at Maine Veterans’ Bangor nursing home. “They get home and suddenly begin to question, ‘What did they say? When do I do this? How do I do this?’ ”

This is exactly why Maine Veterans’ Homes developed its Transitioning Home program for those going home after a short-term or long-term stay in the nursing home. The program is designed to help patients and their caregivers feel confident when transitioning from skilled nursing care to at-home care.

What is the Transitioning Home Program at Maine Veterans' Homes - Bangor?

The Transitioning Home program at Bangor involves a myriad of people and typically begins about two weeks before a patient’s planned discharge.

“We want the patient and their families to feel secure about them returning home,” Michelle says. The program may include various services and is individualized to the patient and his or her needs.

Transition Home Program Examples:

  • A social worker sets up Meals on Wheels and transportation services for doctor appointments and outpatient therapy.
  • A therapist demonstrates at-home exercises and schedules outpatient therapy.
  • A trained staff member educates the patient and family on medication management.
  • The patient uses our therapy apartment suite to practice daily living skills and get safety tips before going home.
  • An at-home evaluation is conducted where recommendations are made to make the home more conducive to recovery.

The Transition Home program is designed to be hands-on so recovery continues as recommended, even when skilled care is not there.

“Our ultimate goal is to make this transition as smooth and successful as possible through education and support,” Michelle says.”We want to improve the patient’s safety and decrease the chance of re-admissions.”

What does the Home Assessment involve?

The at-home evaluation occurs before a patient goes home. A trained professional evaluates the home for safety features and recommendations to help with daily living, such as where to add grab bars, what floor rugs to remove, or how to rearrange furniture for walker or wheelchair accessibility.

“We want to reduce the risks of falls and other potential dangers,” says Traci Kennedy, the senior physical therapist at the Bangor therapy center. “We walk through the home, take measurements and make recommendations to family members or the caregiver.”

Transitioning Home after a Respiratory Illness

Going home after a respiratory illness brings another level of care to the program due to the high risks of respiratory infections and relapses within the first month.

For respiratory patients, a care transition coordinator makes weekly calls and additional visits to help with equipment and medication management at home. At the Bangor home, we hope to expand the coordinator role to provide this additional assistance to others transitioning home also, Bell says.

Scheduling a Rehab and Recovery Stay at Maine Veterans’ Homes

At Maine Veterans’ Homes, we advise patients and caregivers to pre-book post-acute care and therapy for elective surgeries.This helps reduce stress and provides time to complete the necessary paperwork for veteran benefits and eligibility at Maine Veterans’ Homes.

At Maine Veterans’ Homes, we accept veteran benefits while operating as an independent, nonprofit organization separate from the VA. Download your free guide to rehabilitation and therapy eligibility and benefits to get started today. 

MVH Rehabilitation & Therapy Guide to Admission & Benefits