The goal for each patient is discharge from the facility and safe return to home or an assisted living facility. The patient remains on the inpatient rehabilitation unit until they meet the achievable goals set by the interdisciplinary rehab team and physician. The transition to home is an active part of a patient’s rehabilitation program.
Discharge from the inpatient rehabilitation unit and continuity of care for the patient are assured through a planned transition to home-based or outpatient rehabilitation services. The case manager discusses transition to home with the patient and family to determine care needs after discharge provides guidance in finding the resources that will help the patient manage rehabilitation care at home.
The case manager is able to arrange home health care, equipment, and skilled nursing facilities if needed by the patient. He or she will also provide the patient and family with a list of available resources and services including professional nurses, home health aides, physical therapy, occupational therapy, speech pathology, medical social service and laboratory services.