Dr. You

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Transitional Care Checklists

Dr. You’s checklists provide guidance on the key areas to consider during transitions from one care setting to another. Patients, caregivers, registered nurses, families, senior living and social service providers, and other healthcare professionals continuously review the checklists.

The transitional checklists included in this section include:

  • General Hospital Discharge
  • Hospital Discharge to Retirement Community
  • Hospital Discharge to Rehabilitation Facility
  • Hospital Discharge to Assisted Living
  • Long-Distance Relocation to a Retirement Community, Assisted Living, Memory Care, or a Long-term Care Facility
  • Transfer from Rehabilitation Facility to Home 

General Hospital Discharge

There is much to consider when leaving a hospital. Communication between the hospital and all caregivers, service providers, family members, and caregivers is essential for a smooth transition. The following checklist will guide you through the entire process.

Medical Considerations

Discharge Planning

  • Begin discharge planning shortly after being admitted to the hospital by asking to speak with the discharge planner or case manager.
  • Understand the criteria for hospital discharge.
  • Discuss potential discharge dates and plans for transitioning to the retirement community with the hospital, caregivers, and staff from the retirement community.

Medical Stability

  • Work with the doctors to ensure you are stable and your medical condition has improved sufficiently for discharge.
  • Review your vital signs and any necessary laboratory results with providers.

Medication Management

  • Confirm that you and your caregivers have a clear understanding of your medication list, including dosage, frequency, side effects, and any special instructions.
  • Address any changes to the medication regimen.
  • Ensure that you have your prescribed medications before leaving the hospital.
  • Discuss the process for obtaining refills.
  • Discuss any allergies or adverse reactions to medications with the medical team before leaving the hospital.

Symptom Recognition

  • Educate yourself on the signs and symptoms that may indicate a worsening condition.
  • Learn when to seek immediate medical attention.

Follow-up Appointments

  • Schedule and communicate follow-up appointments with appropriate healthcare providers and care team members.
  • Ensure you have the necessary information about the appointment, including the date, time, and location.

Specialized Care

  • Make appropriate arrangements if you require specialized care or follow-up from specific healthcare professionals (e.g., physical therapy, home health care).
  • Ensure that your caregivers and the clinical team at any care setting are informed of any special care needs.

Medical Records

  • Ensure that you have copies and/or access to your medical records and arrange for them to be sent to your primary care physician. This may include, lab and diagnostic test results, images, and radiology, admitting physician information, medical history, clinical notes, progress notes, medication orders and administration, adverse drug reactions, doctors notes, physician orders, nurses notes, consultation notes, treatment plans, care plans, case management notes, vital signs, discharge instructions, consent forms, legal and administrative documents, risk assessments, and safety documentation from your hospital visit.
  • Review your diagnosis and treatment plan with the healthcare team.

Medical Equipment

  • Ensure that you have any necessary medical equipment, such as crutches, oxygen, or monitoring devices.
  • Ask for instructions on the proper use and maintenance of medical equipment or supplies you will be using.

Patient Education

  • Make sure that you have a copy of your Discharge Instructions
  • Ask your doctors and healthcare team to explain the discharge instructions, including activity restrictions, dietary guidelines, and signs of potential complications.
  • Ensure that any instructions are provided in writing in a language the patient understands.

Family and Caregiver Involvement

  • Discuss the family and caregiver involvement level during rehab with the rehab team.
  • Provide contact information for family members and caregivers.

Caregiver Training

  • If applicable, train family and caregivers involved in the patient’s care.
  • Ensure that you and your caregivers understand how to administer medication, wound care, and other relevant tasks.

Logistical and Practical Considerations

Transportation

  • Confirm that you have a safe and reliable means of transportation when leaving the hospital.
  • Arrange for any necessary medical transport if required.
  • Plan for follow-up medical appointments and transportation.

Home Environment

Assess your home environment for safety and accessibility.

Address any potential hazards or barriers to recovery.

Dietary Needs

  • Ask for dietary recommendations to be included in the discharge care plan.
  • Ensure access to suitable food.
  • Consider any dietary restrictions or modifications.

Psychosocial Considerations

Emotional Well-being

  • Assess your emotional well-being and seek appropriate support or referrals as needed.
  • Consider social work or counseling services if needed.

Support Systems

  • Identify and involve your family, friends, and caregivers in the discharge planning process.
  • Discuss caregiving responsibilities and the support available.

Follow-up Communication

Contact Information

  • Ensure that you have contact information for the healthcare team in case you have questions or concerns after discharge.
  • Confirm that you have the hospital’s contact information.

Alternative Care Settings

When you need more medical care and support than can be provided at home, it’s important to explore alternative care settings to ensure your safety and well-being. Here are some additional steps to consider:

Evaluation of Your Condition

  • Conduct a thorough evaluation of your medical condition to determine the level of care needed after discharge and in the future.
  • Discuss your needs with the healthcare team to gain insight into the specific medical care and support you need.

Extended Hospital Stay

  • If you require ongoing medical care but cannot receive it at home, consider the option of an extended hospital stay.
  • Discuss this possibility with the healthcare team and your insurance provider to determine the medical necessity, coverage, and availability of an extended stay.

Skilled Nursing Facility (SNF)

  • Consider transferring to a skilled nursing facility if you require ongoing medical care and rehabilitation.
  • Work with the healthcare team to identify appropriate facilities and coordinate the transfer.

Inpatient Rehabilitation Facility (IRF)

  • If you require intensive rehabilitation services, consider an inpatient rehabilitation facility as an option.
  • Discuss your rehabilitation goals with the hospital discharge team and work with them to identify suitable facilities.

Home Health Care Services

  • If you can receive care at home but require ongoing medical support, consider engaging home health care services.
  • Home health care professionals can provide skilled nursing, therapy, and assistance with daily activities.

Assisted Living or Residential Care

  • Explore assisted living facilities or residential care options if you need a higher level of assistance with daily activities such as bathing or showering, dressing, transferring from a bed to a wheelchair or chair, eating, toileting, grooming, cooking, or household chores.
  • Consider that assisted living facilities provide varying levels of care and support.

Hospice Care

  • If your condition is terminal, consider discussing hospice care options.
  • Hospice care focuses on providing comfort and support for patients with life-limiting illnesses.

Consultation with Social Services

  • Engage social services and case management professionals to assess available resources and support services.
  • They can assist in navigating the healthcare system and connecting with appropriate care providers.

Insurance Coverage and Financial Considerations

  • Verify your insurance coverage and evaluate the financial implications of the various care options.
  • Explore options for financial assistance or support, if needed.

Family Caregiver Support

  • Assess the availability and capabilities of family members or caregivers to provide additional support.
  • Consider whether external assistance, such as respite care, is needed to relieve family caregivers.

Care Transition Planning

  • Collaborate with the hospital team to ensure a seamless transition to the selected care setting.
  • Ensure that all necessary medical records and information are shared with the new care providers and caregivers, as authorized by the patient or their proxy.

It is crucial to approach these decisions collaboratively with everyone involved in your ongoing care. The goal is to provide a care environment that is most suitable and supportive, tailored to the individual’s needs and circumstances. Regular communication and reassessment of your condition are key components of successful care transitions.

Hospital Discharge to a Retirement Community

Transitioning from a hospital to a retirement community can be complex. Research shows that necessary information is often not effectively communicated from one provider to the next. Patients, their caregivers, family members, and/or loved ones must engage with and communicate effectively with both the hospital and the retirement community to ensure a smooth transition and optimal care during the discharge and return processes.

Medical Considerations

Discharge Planning

  • Begin discharge planning shortly after being admitted to the hospital by asking to speak with the discharge planner or case manager.
  • Understand the criteria for hospital discharge.
  • Discuss potential discharge dates and plans for transitioning to the retirement community with the hospital, caregivers, and retirement community staff.

Medication Management

  • Ensure that you and any caregivers clearly understand the medications, including their names, dosages, and schedules.
  • Discuss any new prescriptions or medications that have been discontinued.
  • Review medication changes and reconcile medications upon discharge.
  • Confirm that prescriptions are filled and ready for pickup.
  • Discuss the process for obtaining refills.
  • Verify that you have the needed support to administer and manage medications at the retirement community.
  • Discuss any allergies or adverse reactions to medications with the medical team before leaving the hospital.

Follow-up Appointments

  • Schedule any necessary follow-up appointments with primary care physicians and/or specialists.
  • Provide contact information for healthcare providers.
  • Plan for follow-up medical appointments and transportation, including arrangements for anyone to accompany you to your follow-up appointment.

Medical Equipment

  • Ensure that any necessary medical equipment (e.g., walkers, oxygen tanks) is arranged and available at the retirement community.

Medical Information

  • Review your diagnosis and treatment plan with the healthcare team.
  • Understand your medical conditions.
  • Ensure that the retirement community is the right setting for recovery. Do they have the necessary expertise, or can you schedule home health care visits to address your medical needs?

Medical Records

  • Ensure that your relevant medical records are shared with the retirement community.
  • Ensure that you can access or have copies of all your medical records. Typically, this can include lab and diagnostic test results, images and radiology, admitting physician admission information, medical history, clinical notes, progress notes, medication lists and orders, adverse drug reactions, doctors’ notes, physician orders, nurses notes, consultation notes, treatment plans, care plans, case management notes, vital signs, discharge instructions, consent forms, legal and administrative documents, risk assessments, and safety documentation from your hospital visit.

Care Plan

  • Collaborate with the healthcare team to establish specific rehabilitation goals.
  • Review the daily schedule and any therapy and treatment plans with the retirement community staff.
  • Address any dietary restrictions or preferences with the retirement community.
  • Schedule a post-discharge appointment with your primary care physician or the appropriate doctor to review your progress within one week after your discharge from the hospital.

Equipment and Assistive Devices

  • Identify any assistive devices, such as walkers or wheelchairs, needed in the retirement community.
  • Ensure the community can provide or accommodate these devices.

Personal Belongings

  • Ensure you have a plan to transfer essential personal items, such as clothing and toiletries, to the retirement community.
  • Label personal belongings to prevent loss.

Transfer Arrangements

  • Arrange transportation to the retirement community.

Communication and Coordination

Emergency Contacts

  • Confirm and update emergency contact information.
  • Provide this information to both the retirement community and any relevant healthcare providers.

Advanced Directives

  • Discuss your healthcare preferences and advanced directives, if applicable.
  • Ensure the retirement community can access a copy of your healthcare proxy or power of attorney documents when needed.

Caregiver and Family Support

  • If you have a caregiver, ensure they are informed of any specific needs or instructions.
  • Discuss the level of family and caregiver involvement you need during recovery.
  • Provide the retirement community with contact information for family members and caregivers.

Emotional and Psychological Support

  • Recognize the emotional impact of the situation and seek support if needed.
  • Ask about available counseling or psychological services from your health insurance provider and other resources.

Mobility and Safety

Home Safety Assessment

  • Conduct a safety assessment at the retirement community to identify and address any potential hazards.
  • Consider any modifications or safety improvements needed for your transfer or return.
  • Arrange for any needed adjustments to the living space.

Mobility Aids

  • Ensure that necessary mobility aids are available and properly adjusted.
  • Fall Prevention: Educate the patient and retirement community staff on fall prevention strategies.

Daily Living

Activities of Daily Living (ADLs)

  • Assess the patient’s ability to perform fundamental self-care activities required for independent living and arrange for support as needed. According to Medicare, ADL’s include:
    • Bathing/Showering
    • Dressing
    • Eating
    • Toileting
    • Transferring/Mobility
    • Walking/Ambulating

Dietary Restrictions

  • Communicate any dietary restrictions or special considerations to the retirement community’s dining services.

Psychosocial Support

Emotional Well-being

  • Address your emotional well-being and seek information on available support services.

Community Engagement

  • Identify opportunities to participate in social activities within the retirement community.

Documentation

Discharge Instructions

  • Ensure that you have clear and written discharge instructions and that they are shared with the retirement community staff.

Insurance Information

  • Confirm that your insurance information is up-to-date, and provide relevant details to the retirement community.

By addressing these considerations, you can help ensure a comprehensive and smooth transition for the patient from the hospital back to their retirement community. Do not hesitate to ask any questions or express concerns to the healthcare team before leaving the hospital or when arriving at the retirement community.

Hospital Discharge to a Rehabilitation Facility

Transitioning from a hospital to a rehabilitation facility is complex. Research shows that information is often not effectively communicated from one provider to the next. It is essential for patients and their family members to communicate with both the hospital and the rehabilitation facility to ensure a smooth transition and optimal care during the discharge and rehabilitation admission processes. This checklist will guide you through the entire process.

Medical Considerations

Medical Information

  • Review your diagnosis and treatment plan with the healthcare team.
  • Ensure that you can access and/or have copies of all your medical records. This may include, lab and diagnostic test results, images and radiology, admitting physician information, medical history, clinical notes, progress notes, medication orders and administration, adverse drug reactions, doctors notes, physician orders, nurses notes, consultation notes, treatment plans, care plans, case management notes, vital signs, discharge instructions, consent forms, legal and administrative documents, risk assessments, and safety documentation from your hospital visit.

Medication Management

  • Confirm that you and your caregivers clearly understand your medication, including the dosages, schedules, and any special instructions.
  • Ensure that you and your caregivers understand the adverse symptoms that would trigger a call to a physician. 
  • Verify the rehab facility’s ability to administer and manage your medications.
  • Discuss any allergies or adverse reactions to medications.
  • Review medication changes. Reconcile your medications upon discharge from the hospital. Additionally, discuss any new prescriptions or medications that have been discontinued.

Rehabilitation Facility Selection

  • Research and choose a rehabilitation facility that specializes in your condition. The CMS Nursing Home and Rehab Compare tool is a good starting point, as is your State Department of Health.
  • Verify the facility’s reputation, credentials, and insurance coverage.
  • Understand the medical conditions and limitations that the person has upon discharge from the hospital.
  • Ensure that the rehab facility has the necessary expertise to address your medical needs.
  • Ensure that the facility has not had multiple Directors of Nursing and Administrators in the last six to twelve months.
  • Ask about the staff-to-patient ratio. While there are no set standards, a safe ratio in emergency departments is typically one RN to four patients. In intensive care, it is one RN to two patients, and in operating rooms, it is one RN to one patient. Medicare.gov provides staffing ratios for most U.S. rehabilitation facilities.
  • Have a family member, advocate, or someone that you trust visit the facility before you or your loved one is transferred from the hospital to the rehabilitation facility. Check for cleanliness, resident satisfaction, activity levels, and staffing adequacy.

Discharge Instructions

  • Ensure that you clearly understand discharge instructions, including activity restrictions, dietary guidelines, and signs of potential complications.
  • Ask for written instructions in a language you understand.

Insurance and Finances

  • Confirm your insurance coverage and any pre-authorization requirements.
  • Discuss financial arrangements and potential out-of-pocket costs.
  • Understand the cost increases associated with additional care or services that may be required.

Equipment and Assistive Devices

  • Identify any assistive devices, such as walkers or wheelchairs, that may be needed during rehabilitation.
  • Ensure the facility can provide or accommodate these devices.

Care Plan

  • Ensure that a copy of the Physician’s Orders and Discharge Care Plan is obtained from the hospital and sent to the rehabilitation facility.
  • Collaborate with the healthcare team to establish specific rehabilitation goals.
  • Review the daily schedule and therapy plan.
  • Address any dietary restrictions or preferences.
  • Within one week of discharge from the hospital, schedule a post-discharge appointment with your primary care physician or the appropriate doctor to review your progress.

Family and Caregiver Involvement

  • Discuss the level of family and caregiver support needed during rehab with the rehab and care teams.
  • Provide contact information for family members and caregivers.

Communication

  • Establish clear lines of communication between the rehab facility, family, and care team. The plan should include a single point of contact who is the primary caregiver.
  • Discuss how you will be informed about daily progress, updates, and any changes in the treatment plan.

Personal Belongings

  • Ensure you have essential personal items, such as clothing and toiletries.
  • Label personal belongings to prevent loss.

Transportation

  • Arrange transportation from the hospital to the rehabilitation facility, whether it is an ambulance or a family member’s vehicle.
  • Plan for follow-up medical appointments and transportation.

Dietary Needs

  • Share dietary recommendations with the rehabilitation facility and ensure that you have access to appropriate food.
  • Discuss dietary restrictions or modifications with the rehabilitation facility.

Advanced Directives

  • Discuss your healthcare preferences and advanced directives, if applicable.
  • Ensure the facility has a copy of your healthcare proxy, DNR, power of attorney, and other legal documents.

Follow-Up Appointments

  • Schedule follow-up appointments with your primary care physician and specialists.
  • Ensure that all necessary appointments are coordinated with the rehab facility and caregivers.

Emergency Contacts

  • Provide the facility with a list of emergency contacts and any special instructions.

Personal Mobility and Independence Goals

  • Share your personal goals for mobility and independence with the rehab clinical and therapy teams.

Rehab Discharge Planning

  • Discuss and understand the criteria for discharge from the rehab facility.
  • Discuss potential discharge dates and plans for transitioning to your home or post-discharge care setting.
  • Arrange for any services and support that will be needed at home or your post-discharge care setting. 

Emotional and Psychological Support

  • Understand and acknowledge the emotional impact of rehabilitation and seek support if needed.
  • Ask your health insurance provider about available counseling or psychological services.

Rehab Team Contacts

  • Obtain contact information for key members of the rehabilitation team (therapists, nurses, social workers, etc.).

Home Environment Assessment

  • Consider home modifications or safety improvements necessary for your return.
  • Arrange for any needed adjustments to the living space.

Hospital Discharge to Assisted Living

There are many different models of assisted living. Models range from group homes in residential neighborhoods to those that specialize in a specific type of care to continuing care communities that offer all levels of living and care. One question that should be considered during a transition from a hospital to an assisted living facility is whether the assisted living facility is capable of providing increased health care services if they become necessary.

Discharge Planning

  • Begin planning for discharge shortly after admission to the hospital.
  • Understand the criteria for hospital discharge.
  • Discuss potential discharge dates and plans for transitioning to an assisted living community, if applicable.

Medical Information

  • Review your medical condition, diagnosis, and treatment plan, doctor’s orders, medication list, and care needs with the healthcare team at the hospital and at the assisted living community.
  • Understand your specific medical needs and limitations and the level of assistance available in assisted living versus skilled nursing care.
  • Make sure that the medical information from the hospital, including care plans, recent diagnoses, MD notes, RN notes, doctor’s orders, progress notes, medication lists, etc., is received by the clinical staff at the assisted living community.
  • Discuss medication management and administration at the assisted living facility.
  • Address any medication allergies or adverse reactions.

Assisted Living Facility (ALF) Selection

  • Research and select an assisted living facility that meets your specific needs.
  • Verify the facility’s licensing, reputation, services, clinical and overall staffing, and available levels of care.
  • Consider location, visiting hours, and family accommodations.
  • Ask what arrangements can be made if care needs increase.
  • Visit the assisted living communities you are interested in if possible. If a visit is not possible, consider having a family member, trusted friend, or placement agency tour the assisted living community for you and video the tour.
  • Review all contracts carefully.
  • Consider and arrange for any necessary modifications or safety improvements to ensure a smooth return to assisted living.

Insurance and Finances

  • Confirm insurance coverage and pre-authorization requirements.
  • Confirm the cost of assisted living and establish the necessary financial arrangements.
  • Discuss the payment structure, potential out-of-pocket costs, and any financial assistance options.

Care Plan

  • Collaborate with the healthcare team to establish goals and a personalized care plan.
  • Review the daily care schedule and any rehabilitation or therapy plans.
  • Discuss dietary preferences, restrictions, and any special dietary needs.

Personal Belongings

  • Pack essential personal items such as clothing, toiletries, and any comfort items.
  • Label personal belongings to prevent loss.

Transportation

  • Arrange transportation to the assisted living facility, whether it is an ambulance or a family member’s vehicle.
  • Plan for follow-up medical appointments and transportation to those appointments.

Communication

  • Establish clear lines of communication between the ALF and your family.
  • Discuss how you and any family members will be informed about your daily care, progress, and any changes to your care plan.

Family and Caregiver Involvement

  • Discuss the level of family and caregiver involvement needed during your stay at the ALF.
  • Provide contact information for family members and caregivers.

Advanced Directives

  • Share your healthcare preferences and advanced directives, if applicable.
  • Ensure the ALF has a copy of your healthcare proxy, DNR, power of attorney, or any other legal and important documents.

Emotional and Psychological Support

  • Recognize the emotional impact of transitioning to assisted living and seek support if needed.
  • Ask about available counseling or psychological services at the ALF.

ALF Team Contacts

  • Obtain contact information for key members of the assisted living facility’s team, including caregivers, nurses, social workers, and other relevant personnel.

Follow-Up Appointments

  • Schedule follow-up appointments with your primary care physician or specialists.
  • Ensure that all necessary appointments are coordinated with the ALF.

Emergency Contacts

  • Provide the ALF with a list of emergency contacts and any special instructions.

Familiarize Yourself with Assisted Living Facility Policies

  • Familiarize yourself with the rules and policies of the assisted living facility, including visiting hours, meal schedules, and safety protocols.

Do not hesitate to ask any questions or express concerns to the healthcare team before you leave the hospital and enter the assisted living facility.

Customize this checklist to your specific needs and medical condition. Effective communication with your healthcare team and the staff at the assisted living facility is crucial for a successful transition and quality care during your stay.

Long-Distance Relocation to a Retirement Community, Assisted Living, Memory Care, or a Long-term Care Facility

Preparing for a loved one’s long-distance relocation requires careful planning. Few people are completely ready for this type of move. Reassure the person relocating that it is natural to experience fear, apprehension, and many other emotions, and that in most cases these emotions subside after a few weeks. Encourage the person moving to talk to someone they trust. This will help ease concerns about the transition. This checklist will help you through the entire process.

Assessment of the Person’s Needs

  • Evaluate the level of care the person requires (e.g., independent living, assisted living, memory care).
  • Consider any medical conditions, mobility issues, or particular care needs.

Research Local Communities

  • Explore retirement communities or assisted living facilities in your local area.
  • Consider factors such as proximity to family, quality of care, amenities, and cost.

Visiting Potential Facilities

  • Schedule visits to the selected communities to assess their environment, cleanliness, resident engagement, dining services, and staff interactions.
  • Talk to current residents and their families to gather feedback.

Financial Planning

  • Understand all the costs associated with the chosen community, including rent, food services, care services, buy-in fees, and other fees.
  • Determine the budget for the move and ongoing living expenses. Discuss how additional care needs would affect the monthly cost.

Legal and Financial Documentation

  • Review legal and financial documents, such as contracts, wills, powers of attorney, and healthcare directives.
  • Ensure that these documents are updated and accessible.

Downsizing and Packing

  • Although it can be emotional, consider what personal belongings to bring to the new living space, what to sell, give to family members, put in storage, donate to charity, or throw away.
  • Arrange for the packing and transportation or storage of furniture and essential items.

Moving Logistics

  • Plan the coordination of the move, including hiring a moving company or coordinating transportation.
  • Ensure that the new living space is accessible for the person’s needs.

Settling into the Community

  • Help the person acclimate to their new home environment by introducing them to staff, residents, and activities.
  • Set up your living space with familiar items to make it feel like home.

Social and Emotional Support

  • Offer emotional support during the transition.
  • Encourage the person to participate in community activities to foster social connections.

Communication Plan

  • Establish a communication plan to stay in touch with the person regularly.
  • Exchange contact information with key staff members at the new community.

Ongoing Evaluation

  • Discuss how the person’s well-being and satisfaction in their new living arrangement will be monitored and communicated with loved ones.
  • Address any concerns or issues promptly.
  • Remember that each family and situation is unique, so feel free to customize this checklist based on your specific circumstances.

Healthcare Coordination

  • Coordinate with the person’s healthcare providers to transfer medical records and prescriptions to local providers.
  • Verify insurance coverage for services at the new location and arrange payment for any non-covered services.

Medical Assessment

  • Obtain a detailed medical assessment from the person’s current healthcare providers.
  • Share this information with the medical staff at the chosen community to ensure they can provide the necessary level of care.

Specialized Care

  • Determine if the chosen community has experience and expertise in managing specific medical conditions.
  • Inquire about on-site medical services and the availability of skilled nursing care if needed.

Medication Management

  • Discuss the community’s procedures for medication management.
  • Ensure that staff members are trained to administer medications if required.

Emergency Response

  • Understand the community’s emergency response protocols.
  • Confirm the availability of medical personnel and the proximity to healthcare facilities.

Accessibility and Safety

  • Evaluate the accessibility of the living area, considering mobility aids and safety features.
  • Confirm that staff are trained to assist residents with mobility challenges.

Healthcare Proxy and Directives

  • Ensure that the person’s healthcare proxy and directives are up to date and on file with the community.
  • Provide copies to relevant staff members.

Regular Health Monitoring

  • Discuss how the community regularly monitors each resident’s health.
  • Inquire about the process for notifying family members in the event of health changes or emergencies.

Specialized Services

  • If the person requires specific therapies like physical therapy or occupational therapy, inquire about the availability of these services on-site or nearby.

Communication with Healthcare Providers

  • Establish a clear communication channel between the community’s medical staff and the person’s primary healthcare providers.
  • Ensure that medical records can be easily shared and updated.

Transportation for Medical Appointments

  • Confirm the availability of transportation services for medical appointments outside the community.
  • Understand any associated costs and scheduling procedures.

Family Training

  • If applicable, inquire about opportunities for family members to receive training in assisting with the person’s specific medical needs.

Infection Control Measures

  • Inquire about the community’s infection control measures, especially important if the parent has a compromised immune system.

Fall Prevention

  • If the parent is at risk of falls, discuss fall prevention measures in the living space and common areas.

By addressing these additional considerations, you can ensure that your loved one receives the appropriate level of medical care and support in the new living environment. Regular communication with the community’s staff is crucial to staying informed about your loved one’s health and well-being.

Transfer from Rehabilitation Facility to Home

Preparing for a loved one’s discharge from a rehab facility and their return home can be complicated and often requires additional services and support that require careful planning. This checklist will guide you through the entire process.

Planning

  • Begin discharge planning very shortly after admission to the rehabilitation facility.
  • Meet with the discharge and medical planning teams to determine how they can contact any family members or key individuals assisting the patient.
  • Ask the social workers at the rehab facility if someone from the medical team will assess the home environment prior to discharge for safety and to make sure that it meets the patient’s needs for care and continuing therapy.

Consult with the Rehab Team

  • Meet with the rehabilitation team to discuss the care plan after discharge.
  • Understand the patient’s progress, limitations, and ongoing care needs.

Coordinate Transportation

  • Arrange transportation from the facility to the home.
  • Ensure the mode of transportation is suitable for the patient’s mobility needs.

Home Environment Preparation

  • Ensure the home is clean, safe, and accessible.
  • Remove obstacles and hazards, such as loose rugs or clutter.

Accessibility

  • Consider mobility aids like grab bars, handrails, or ramps if needed.
  • Confirm that the home is wheelchair- or walker-friendly.

Medication Management

  • Understand your loved one’s medication schedule and any changes made during rehab.
  • Get a copy of the medication list and prescriptions.
  • Ensure you have an adequate supply of medications and a system for organization.

Medical Equipment

  • Arrange for any necessary medical equipment or supplies (e.g., wheelchair, shower chair, oxygen).
  • Ensure that supplies are properly set up and ready for use.
  • Ask for a demonstration of any medical equipment that will be used in the home.

Caregiver Support

  • If needed, arrange for a caregiver or home healthcare aid.
  • Train caregivers on your loved one’s specific care requirements.

Home Health Services

  • Schedule any home health services, such as physical therapy or nursing visits.
  • If possible, arrange for any caregivers to meet your loved one while they are still in the rehabilitation facility.

Follow-Up Appointments

  • Ensure all follow-up appointments with healthcare providers are scheduled and attended.
  • Have transportation arrangements for these appointments.
  • Schedule an appointment with your loved one’s primary physician within one or two weeks after their discharge. 

Communication with Healthcare Providers

  • Make sure you have a list of emergency contact numbers for healthcare providers.
  • Understand the signs of potential complications and when to seek medical attention.

Nutrition and Meal Preparation

  • Plan for appropriate meal options that meet dietary restrictions.
  • Consider meal delivery services if cooking is difficult for your loved one, and their caregivers, family, and/ or friends are not available to make meals for a brief period once the patient returns home.

Support Systems

  • Reach out to friends and family members for emotional support and assistance.
  • Discuss a schedule for visiting and helping your loved one once they are settles in at home.

Emergency Preparedness

  • Ensure the patient has access to a phone or medical alert system.
  • Develop an emergency plan, including contact information for neighbors or friends.
  • Familiarize yourself with the location of the nearest hospital and ensure you have plans in place to support your loved one in the event of a medical emergency.

Personal Hygiene and Bathing

  • Make sure the bathroom is safe and accessible for bathing.
  • Arrange for assistance if necessary.

Home Rehabilitation Exercises

  • Encourage and assist with any prescribed home exercises or physical therapy.

Mental Health and Emotional Support

  • Recognize the emotional impact of the transition and provide reassurance.
  • Consider seeking counseling or joining a support group if needed.

Finances and Insurance

  • Review insurance coverage for ongoing medical needs.
  • Address any financial concerns related to your loved one’s care.

Medication Education

  • Ensure the patient and caregivers understand the medications, their dosages, and any potential side effects.

Monitor Progress

  • Keep a journal or chart to track your loved one’s progress and changes in health after they return home.

Relaxation and Recreation

  • Encourage activities that improve the patient’s mental and emotional well-being.

Few people are completely ready for this type of move. Yet, most patients are very happy to be going home. Reassure the person transitioning from the rehabilitation facility back to their home that it is natural to experience fear, apprehension, and a range of other emotions, and that in most cases, these emotions subside within a few weeks. Encourage the person moving to talk to someone they trust. This will help ease concerns about the transition.

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