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Graceworks at Home: Good Communication Helps with Successful Rehab

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Good communication helps with successful rehab
Dayton Daily News | April 10, 2017
Marci Vandersluis |

When talking with families about a parent, personal or spouse’s experiences at care facility, it was not terribly surprising that the reviews were mixed. Some acknowledged that while they felt that staff members were doing their “best,” they felt some frustration that concerns were not always addressed timely, or to their specifications.

With a focus toward creating a patient-centered care experience it is unfortunate that many people find themselves feeling that their support is far from personalized. I do think however, that care facilities want to do better, and one key tool to help all stakeholders is to encourage open communication from pre admission throughout the stay in the facility.

If in the process of looking at temporary or longer term supportive housing options, it will soon become pretty evident that there are many options to choose from. Most would agree that an invaluable first step would be to do your homework. The Medicare website offers information on skilled nursing/rehab facilities and ratings based on such factors as health inspections and staffing with a five star being the highest level. This site can be a good starting point when a rehabilitation or skilled nursing stay is anticipated. Should time permit, it is encouraged to visit preferred facilities to help (as best able) insure a good match.

To make the most of the visit come prepared with a list of questions specific to personal expectations. This can help best determine that your objectives are in sync with the facilities culture. Late risers, for example, may want to review options regarding their flexibility with dining options. While touring, request a brief meet and greet with a member of the therapy team to review a typical therapy schedule. Ask about room options, staffing, vacancies, review the menu and activity schedule and inquire about ancillary services of personal interest such as location, or if there is Wi-Fi capability. When a short list of rehab centers has been determined, contact your health insurance to find out about coverage as well as if a three-night in patient hospital stay is required. Inquire about possible out of pocket costs and confirm that the facility of interest is in network.

Time in a skilled rehab should ideally focus on progressing in therapy. A key goal is for person to progress towards his “prior level of functioning” in order for him to get back to his routine activities of daily living. A beginning step to accomplish this task is to meet with the multidisciplinary team of the rehab shortly after admission. Use this time to talk about one’s daily schedule particularly as it relate to therapy sessions. In doing so, staff and family can be mindful to book an outside medical appointment or plan a social visits after these sessions. The team meeting is also a great time for the patient and/or family to share any relevant concerns that may impede success after discharge.

For example, if mom was experiencing significant challenges at home even prior to her fall and subsequent hip fracture, best to share this information with the team at the beginning of the stay rather than soon before discharge. In doing so, community services such as home delivered meals, home health care or needed medical equipment such as an emergency response pendant can be arranged to be in place when the individual returns home. Pre planning can also help if there is need for some new medication, treatment or lifestyle education. This can help to minimize the risk of the very uncomfortable and often-ineffective scramble for services particularly when a discharge occurs sooner than anticipated.

A readmission to a skilled rehab within a short period does not bode well for care providers or recipients. Medicare frowns on readmission within 30 days of discharge with the risk of significant financial penalties. Not surprisingly, the recipient may also find that “bouncing” from home back to a skilled rehab to be very unsettling. To help minimize this from happening, keep the dialogue going from day one. If there are concerns or issues that cannot be resolved at the facility, do not hesitate to contact not the local Ombudsman for assistance.

Marci Vandersluis is a licensed social worker for Graceworks at Home and has a master’s degree in gerontology. With many years of experience helping adults achieve this desire for independence, Graceworks at Home is uniquely qualified to serve individuals requiring a little extra assistance. Call 937-436-7700 to schedule an assessment or to request more information.

Written by Bethany Village

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