If My Loved One Is Not Going Home, Where Do They Go?
Of course the goal is to go home following the rehabilitation stage, but that may not be the best route for all individuals and their loved ones. Here are some examples of what discharge may look like…
1. Subacute Care: A subacute can also be referenced as “SNF” or “Skilled Nursing Facility.” A subacute will have specialized nursing care, therapy, and medical monitoring in a less acute setting than a hospital. Subacute care aims to continue stabilizing the person medically while preparing them for the next phase of the continuum of care. These can also be known as “Transitional Facilities.”
2. Assisted Living Facility: Assisted living facilities are ideal for patients who need some assistance with activities of daily living but do not require the level of medical care provided in a nursing home. These facilities offer services such as meal preparation, medication management, housekeeping, and personal care assistance. Residents in assisted living facilities typically have their own living space, such as a private room or apartment, and can maintain a level of independence while receiving support as needed.
3. Long-Term Care Facility: Also known as nursing homes or skilled nursing facilities, these are suitable for patients who require ongoing medical care and supervision. Patients in long-term care facilities often have complex medical needs or disabilities that require 24-hour nursing care. These facilities provide assistance with medication management, activities of daily living, and medical treatments. They may also offer recreational activities and social support for residents.
4. Group Home: Group homes are residential settings that provide care and support for individuals with disabilities, including brain injuries. These homes may have staff members available 24/7 to assist residents with daily tasks, medication management, and medical appointments. Group homes offer a structured environment with opportunities for social interaction and community engagement. They are often smaller and more intimate than larger care facilities, allowing for more personalized care.
The choice of setting depends on factors such as the patient's medical condition, level of independence, family support, financial resources, and available community services. Healthcare professionals, including social workers and case managers, can help guide patients and their families in making informed decisions about post-rehabilitation care options.
How do we come up with the best decision?
The care team, with the social worker playing a crucial role, plays an integral part in helping patients and their families make decisions about post-rehabilitation care options after discharge from an inpatient rehabilitation facility for brain injury. Here's how the care team, including the social worker, can assist with this decision-making process:
1. Assessment: The care team conducts a comprehensive assessment of the patient's medical condition, functional abilities, cognitive status, and psychosocial needs. This assessment helps identify the level of care and support the patient requires upon discharge.
2. Information Provision: The social worker provides information about different post-rehabilitation care options, including transitional care facilities, long-term care facilities, assisted living facilities, group homes, and home-based care with caregiver support. They explain the services available in each setting, associated costs, insurance coverage, and eligibility criteria.
3. Collaboration: The social worker collaborates with the patient, their family members, healthcare providers, and other members of the care team to gather input and insights into the patient's preferences, goals, and priorities. This collaborative approach ensures that decisions align with the patient's values and wishes.
4. Supportive Assistance: The social worker offers supportive assistance and emotional support to the patient and their family throughout the decision-making process. They address concerns, fears, and uncertainties, providing guidance and reassurance during this transitional period.
5. Resource Referrals: The social worker connects patients and families with community resources and support services, such as local agencies, support groups, respite care programs, and financial assistance programs. These resources enhance the patient's overall well-being and support the caregiving process.
6. Advocacy: The social worker advocates for the patient's best interests, ensuring that their preferences are respected and that they receive appropriate care in a setting that meets their needs. They may also advocate for access to necessary healthcare services, therapies, and assistive devices.
7. Transition Planning: The social worker assists in developing a comprehensive transition plan that outlines the steps, timelines, and responsibilities involved in transitioning from the rehabilitation facility to the chosen post-rehabilitation care setting. This plan may include coordination of medical appointments, medication management, caregiver training, and communication strategies.
By providing personalized support, education, advocacy, and coordination of services, the care team, led by the social worker, helps patients and families navigate the complex decision-making process and ensures a smooth transition to post-rehabilitation care.
