From Hospital to Home: Navigating the Next Phase of Care
Being in the hospital after sustaining a traumatic event is an all-around experience. Whether it be a stroke, heart attack, fall, or exacerbation of chronic diseases/conditions such as Parkinson’s, heart failure, etc., this is a time when emotions are especially high, all while you’re not feeling well. Depending on the circumstances, there can be a range of emotional states such as shock, grief, delirium, defeat, and frustration, to gratitude and revelation. While navigating and processing this spectrum of emotions, you also must grapple with some big potential decisions about what happens next. This is the tricky part, as decisions made during this transitional point in care can have critical, long-term implications if made hastily or without proper planning. If you’re in the hospital or perhaps you have a loved one there, we are here to make sure you have the information you need.
There is a plethora of resources available to help guide you- you do not have to do this all on your own - it’s time to ‘call in the cavalry’. Hospitals offer a variety of support – this piece is here to help you identify different levels of care available to you, know how to ask for help, and prepare you for the big decisions prior to being discharged home after a traumatic event.
Often, we see people go to the hospital, and of course, their goal is to get home as fast as they possibly can, no matter what. Completely understandable. Unfortunately, the reality is that it is a rarity to have a perfectly fantastic recovery & transition back home without a glitch or modification to life prior to the traumatic event. For most cases, rushing back home due to eagerness to be discharged as quickly as possible can be a mistake. It is important to acknowledge what your body has been through and to accept the time to heal under the guidance of medical professionals while designing a plan for long-term success to hopefully avoid future hospitalizations or drastic changes to quality of life.
There are several what we would call ‘levels of care’- we’ll touch on a few of the most common:
First and foremost, we have the hospital setting, which we would call acute care. After the acute setting, we have some decisions to make – between you, your doctors/clinical professionals, and your support system.
If you’ve suffered a more severe incident, a level of care to consider post-acute is inpatient rehabilitation. These inpatient rehabilitation centers require a certain qualification from your doctor and insurance to meet medical standards and to ensure that you can participate in the level of rehabilitation offered. This can be a fantastic place to heal and learn during a short stay with physical, occupational, and speech therapists to support you while you engage in intensive rehabilitation.
If inpatient rehabilitation is not an option after our acute stay, the next option would be to look at skilled nursing. This level of care is also an inpatient stay at a facility that offers rehabilitation and potential long-term medical care for those who may require more support for an extended period of time, or as a permanent residence. In this setting, the focus continues to be on healing while receiving rehabilitation services. Care plan meetings are held to review your progress and to provide guidance on your transition back to the home environment or to help you decide on continued support that might be needed in the form of assisted living, personal care, or independent living. From skilled nursing, there are two paths we typically venture down.
Path # 1 - We can safely transition to the home environment with home health services if it is recommended by the therapy team. Returning home with home healthcare would mean that a nurse, physical therapist, speech therapist, and occupational therapist could come to the home at designated points during the week to do functional therapy to ensure you are successful at home. Once home health is completed, we can look to graduate to an outpatient therapy center in your community to continue working on progress toward higher-level skills with the goal of getting back to ‘normal’ or your new baseline.
Path # 2 - If we’re not able to return home with home health due to requiring continued support after skilled nursing, many assisted living/personal care facilities offer respite stays, which are designated periods of time you can reside in the facility to receive their staff support for ADLs/mobility/meals/medical care, while utilizing therapy services. A warning to those pursuing respite stays in personal care: many of these facilities report they offer therapy services, but please ask whether they have in-house therapy on-site or if they have traveling therapists who come on-site when requested. We would always highly recommend a facility that offers therapy onsite daily to ensure you receive your visits and have access to equipment to restore you. At the completion of a respite stay, there is another decision- Have you rehabilitated to the level where to return home safely (return to Path # 1!) or would it be beneficial to you to take residence in an assisted living/personal care or independent living facility to receive support?
There are many choices and, unfortunately, choices that must be made in a short period of time. Everyone wants to be at home; no one wants to spend time in the hospital or a strange place (especially when they’re not feeling well), but allowing yourself the time to heal and restore yourself can mean the difference between going home and thriving versus going home and barely surviving, only to sustain a fall or another medical event shortly after.
Let’s talk about the people who act as resources available to help navigate these big decisions!
It can be hard to ask for advice and to accept help (I am personally as stubborn as the day is long and will most definitely be difficult someday in this position myself)—but this is absolutely the time to do so. It can make all the difference in terms of maintaining your quality of life and independence. In the hospital, ask for an elder care advocate or social worker to support you. These professionals will provide resources and help you break down options on the table regarding discharge. They should act as a care liaison and ensure you have the information you need to make informed decisions. A step further, and something that we recommend if you are able, is to hire a private medical consultant/liaison. These professionals are typically nurses, therapists (PT/OT/ST), or social workers by background and now take on individual cases to ensure their clients have the support they need to make the best decisions for their specific situation. Once you return home (even potentially a new home in assisted living/personal care/independent living), there are advocates & consultants who can be hired to perform safe home evaluations and make recommendations for products to support independence with activities of daily living and to reduce fall risk within the environment. These professionals typically label themselves as senior care consultants or concierge.
Moving forward with the right support
Length of stay is a hot-button topic in hospitals, and hospitals themselves can pose risks when time is extended– there is a general feeling to rush to leave the environment for many reasons. Healing isn’t a race— it’s a journey that deserves care, patience, and the right support. Surround yourself with the right professionals and advocates who can guide the way. It’s important to trust that each thoughtful step forward helps build the foundation for lasting wellness. Use the resources around you, ask questions, and give yourself the grace to heal well—not just quickly.
Dina Holland MS, CCC-SLP, CDP
“A goal without a plan is just a wish”
Everyone’s journey for healing is different. This post highlights a typical path we see in senior care post-hospitalization and is not medical advice. Please consult your doctor, therapy team, and support network to make the best choices for your situation.