How we help
Coming home after a rehab or nursing facility stay
After a hip, a stroke or a long hospital stay, many people spend a few weeks in short-term rehab before going home. The rehab team says your parent is ready, but the house has not changed. Here is how to plan help at home after rehab, one step at a time.
Help planned before the move home; when we hear the date early, we work to have a caregiver at the house on discharge day from the rehab center or nursing facility.
Help with the routines rehab practiced: bathing, dressing, toileting and transfers, with a hand nearby.
Medication reminders that follow the facility's discharge list; caregivers remind and assist, they do not administer.
Hours around the home health nurse and therapist visits, so practice continues between them.
Daytime, overnight or 24-hour coverage for the first weeks, adjusted as your parent's needs change.
When does a rehab stay end?
A short-term rehab stay ends when the therapy team decides your parent no longer needs daily skilled care, or when insurance coverage stops, and those are not always the same day. Medicare Part A covers skilled nursing facility care for up to 100 days in a benefit period, but only while the person needs and receives daily skilled care, and only after a qualifying inpatient hospital stay of at least three days in a row; time spent under observation does not count. Most stays end well before day 100. When Medicare coverage is ending, the facility must give your parent a written Notice of Medicare Non-Coverage at least two days before services end. If you think it is too soon, the notice explains how to ask for a fast appeal from the independent reviewer named on it, and the deadline is noon of the day before services end. Medicare Advantage plans follow their own approval rules, so ask the facility's social worker how your parent's plan handles discharge.
Questions to ask before discharge
- What can your parent do alone now, and what still needs someone standing by: the shower, the toilet, stairs, getting into a car?
- Which home health services are ordered after discharge, and which agency will provide them? You can ask for a list of agencies that serve the address and choose among them.
- What equipment is ordered, such as a walker, wheelchair, shower bench or raised toilet seat, and when will it arrive?
- Which medications changed during the stay, and will the prescriptions be ready the day your parent leaves?
- Can a family member or caregiver watch a therapy session before discharge to learn how the transfers are done?
Then call us at (717) 695-2704. A care coordinator asks about mobility, the house and family schedules, and arranges an in-home consultation, usually within one to two business days in the Harrisburg area and a little longer in outer counties.
The first week home
The first week home is the test of everything rehab practiced. In the facility there was a call bell, grab bars everywhere and staff down the hall. At home there is a bathroom at the top of the stairs and a recliner that is lower than the rehab chair. When we know the date early, we work to have a caregiver there when your parent arrives to help them settle, prepare a meal and give Medication Reminders that follow the discharge list. Over the following days the caregiver provides personal care such as help with bathing, dressing and toileting, stands by for transfers the way the therapists taught them, keeps paths clear, does laundry, and goes along to follow-up appointments. Many families start with overnight care or 24-hour care for the first week or two and step down when the family feels ready. Our home safety checklist is worth going through before discharge day.
Working alongside home health
Home health is usually the next step after rehab, and it is a separate service from ours. A home health agency sends nurses and therapists for short visits a physician orders, and Medicare generally covers them for patients who qualify. Our caregivers provide the non-medical hours between those visits. We do not provide nursing, therapy, wound care or injections. With your permission, the caregiver notes what the therapist asked your parent to practice and encourages it between visits. See home care vs. home health care.
Paying for help at home after rehab
Medicare does not pay for ongoing non-medical home care, so the help in between home health visits is usually paid privately or through long-term care insurance, which often begins once a person needs help with two or more daily activities. Veterans and surviving spouses may have VA benefits. Older adults with limited income and assets may qualify for OPTIONS through the county Area Agency on Aging, and Medicaid-eligible adults may receive services through Community HealthChoices. We accept all of these. If the rehab stay followed a discharge from a hospital we cover, see coming home from the hospital for the hospital-specific pages. It's Your Home Care is an independent agency licensed by the Pennsylvania Department of Health and is not affiliated with any rehab center or nursing facility.
Other situations we help with
Coming home from the hospital
The hospital wants the bed. The discharge planner says someone needs to be home. You have a job, kids, and maybe a two-hour drive. This is the situation we are built for.
After surgery
A hip, a knee, a heart, a back. The surgeon says recovery at home is fine as long as someone is there. You want to say yes to that. Here is how to make it true.
After a stroke
A weaker side, a walker, slow words and a calendar full of therapy. A caregiver handles the transfers, the showers and the long days between appointments so the family is not doing it alone.
After a fall
A fall changes everything in a day. Whether it ended in the ER or just a scare on the kitchen floor, the question is the same: how do we keep this from happening again without taking away their independence?
Frequently asked questions
How long does Medicare pay for short-term rehab in a nursing facility?
What can we do if the rehab center says Medicare coverage is ending too soon?
Does Medicare pay for a caregiver after rehab?
Can a caregiver help with transfers the therapist taught?
How soon can we get help at home after rehab?
Sources
- Skilled nursing facility care — Medicare.gov
- Fast appeals — Medicare.gov
- Home health services — Medicare.gov
This article is general information for Pennsylvania families and is not medical, legal, financial, or insurance advice. It's Your Home Care is a non-medical home care agency licensed by the Pennsylvania Department of Health; we do not provide skilled nursing or medical services. Program rules and eligibility change; confirm details with the agency or program named, your physician, or a qualified advisor before making decisions.
Talk to a care coordinator today
Tell us what is happening at home. We will explain your options, including what private pay, long-term care insurance, VA benefits, and Pennsylvania waiver programs may cover, and schedule an in-home care consultation when you are ready.