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Guest Blog: Too Well for Rehab, Not Well Enough for Home

Published April 25, 2014

Our Guest Blogger this week is Susan Yubas, a Certified Senior Advisor (CSA)® and the Founder of  FYI Senior Living Solutions. With over thirty years of health care management experience, she is able to assist seniors and their families in navigating the housing, social, financial and healthcare complexities related to aging.  She is knowledgeable in the regulatory and functional requirements of senior housing, and has provided strategic planning and development services to health care providers across a continuum of care.

Despite our hopes, being discharged from rehab to home is sometimes complicated and inappropriate.

A family member recently had an extended hospital stay followed by a few weeks in a rehabilitation facility for therapy to regain physical strength.  He only longed to go home and sleep in his own bed in his own home. We all know how wonderful that would eventually be, but being discharged from rehab to home is sometimes complicated and inappropriate.

A hospital stay can be disorienting for the best of us, but more so for older adults, making the transition to home more difficult.  Some of the potential issues include:

Managing their medications when the previously known medication regimen has changed from what they recall it was before they went into the hospital

Their ability to get around on their own might have changed and they forget that they cannot get out of bed, up from a chair without assistance or are unsteady on their feet , leading to an increased risk of falling

Meal preparation may be overwhelming so they may not eat a well- balanced nutritious diet, or they may not eat at all.

Depending upon the person’s condition, assistance may be needed in monitoring their health in the initial weeks and months following discharge.  Early identification of symptoms that may indicate that they are not fully recovered or that there is a decline in their health is critical.  Sometimes, this is accomplished successfully by friends and relatives or by the hiring of a private home health aide.

Since our family member had children who work and were not around during the day; he did not want someone to live in his home with him; it was difficult for him to get out and about on his own and since his friends had traveled to warmer climates for the Winter months, he chose to take an interim step that may become more permanent:  with encouragement from his family, he moved into an assisted living community for the time being until they could all agree it was safe to move back home.

The benefits have been terrific and he is thriving – he is dressed and out of bed each morning and eating well.  He has found new friends to play cards with, and discuss politics and world events.  At the same time, he has the comfort of his own apartment within the assisted living community to go to when he wants his private time.

After dinner at his daughter’s house, he announced that it was “time to go home.”  She said “Dad, you mean to your apartment?”  “Yes,” he replied.  “My new one.”

The definition of home has changed.

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