Rehab to Home
Transitions Program

Rehab to Home Rehab to Home Transitions Program

There are many benefits to healing at home. However, older adults and their families are often unprepared for the challenges that come with it. Therefore, Careplan’s RN’s and Licensed Social Workers ease those challenges. They make the day-to-day routine easier to manage. This allows older adults to focus on the most important thing – getting better.

Why Should You Consider the Rehab to Home Transitions Program?

Half of Medicare patients who are re-hospitalized within 30 days have not seen a doctor during the entire month. This is according to a 2009 study in The New England Journal of Medicine of almost 12 million Medicare beneficiaries.

Patients forget up to 80 percent of what health-care providers tell them. Consequently, what they do remember is wrong almost half the time. This is according to a 2003 study in the Journal of The Royal Society of Medicine.

The study found that nearly 20 percent of people 65 and older on Medicare are readmitted within 30 days of their initial rehab discharge. (reported in The New England Journal of Medicine)

Nearly 20% of 30-day re-admissions are likely preventable. In addition, rehab readmission rates are, in large part, influenced by other factors outside of the rehab domain. These include poor social support, poverty, and access to outpatient care. This is according to a study in the US National Library of Medicine National Institutes of Health.

The New England Journal of Medicine
Journal of The Royal Society of Medicine
US National Library of Medicine National Institutes of Health

The Rehab to Home Program consists of a total of 2-3 Geriatric Care Manager (GCM) visits to the senior’s home. 

Bridget Ritossa, LSW, CMC, Careplan’s Rehab to Home Care Manager, worked for many years in hospitals and Rehab settings as a discharge planner. Bridget understands what’s necessary for success upon discharge.

  • The first visit occurs at the Rehab Center prior to discharge. This allows Careplan’s Rehab to Home Geriatric Care Manager (GCM) access to the senior and their records. At this time, the GCM will set post-discharge goals alongside the rehab discharge record.
  • The second and third subsequent visits occur in the home. This is with family present if able. At this time they review medications, discuss any barriers to care, as well as review the discharge plan of care. In addition, the GCM will check if follow up appointments with physicians have been made.
  • Home visits are scheduled at 60 minutes for the first visit. The remaining visits are scheduled for 30 – 60 minutes. The senior is encouraged to share a list of questions or concerns with the GCM. During home visits, the Rehab to Home GCM will see if follow up appointments have been made. They will also check to see if transportation is in place. At this time, the GCM will check to see that prescriptions are filled and being taken as directed. Finally, the GCM will make recommendations for change. They will also provide strategies to further ensure the senior’s safe transition from the Rehab Center.