From Rehab to Home

At Home Care Assistance, we are committed to the wellbeing and safety of the clients we are privileged to serve. Many of our clients come to us following a rehabilitation facility stay. The transition from rehabilitation/skilled nursing facility to home can be a challenging one for patients and their families. One of the leading causes of readmission or slow post-recovery is the lack of proper support immediately following a discharge. The transition out of the security of the facility setting may seem daunting at first, but remember that you are not alone in this process.

A stay in a rehabilitation center is typically covered by Medicare. These benefits will frequently cover three to four hours per day of active rehabilitation—whether that is physical therapy, occupational therapy, or speech therapy. Additionally, each rehab facility is overseen by a Registered Nurse and every patient is assisted by Certified Nursing Assistants. For skilled nursing facilities, the Medicare benefit pays for several weeks of care so long as the patient demonstrates progress in therapy, or that the condition is unstable enough to require around the clock skilled nursing.

The discharge planning team at the facility is responsible for coordinating a patient’s transition out of the rehabilitation facility and his or her post-recovery at home. But you are free to choose the home care company that best fits you and your needs. We offer qualified certified nursing assistants to help you when you return home to continue your rehabilitation.

Working with a personal rehab to home caregiver provides the individual customized attention, ranging from a few hours a day to around-the-clock care 24 hours a day. Likewise, visiting therapists can cater to the specific recovery needs of a client at home. Caregivers and certified nursing assistants can help to maintain therapy workout routines after the therapy sessions have officially ended. For most adults transitioning out of the rehabilitation setting, home care is the solution that offers the greatest security and happiness for the client, giving peace of mind to his or her family.

The rehab to home caregiver or certified nursing assistant can provide dedicated one-on-one support at a level beyond the services of a rehabilitation facility. Caregivers are dedicated to their clients full-time to support their range of needs from meal preparation, transportation, medication reminders and housekeeping to more complex needs associated with chronic conditions. Rehab to home care can be an integral part of healthy patient recovery and quality of life following a rehabilitation period. Home Care Assistance provides a personalized care plan for your specific situation.


As you plan for your recovery, keep in mind that it can be a gradual process. Recovery typically follows a six-step progression and can require anywhere from a few weeks to months, depending on the cause of your hospitalization. As you progress through these steps, you should constantly evaluate your own strength and confidence. You should never move on to the next step until you are ready.

  • Dependence – We can help with the transition to home by meeting you at the facility and helping you get your loved one settled comfortably at home. When you first return home after your hospitalization, your primary goals should be rest and recovery. Your caregiver is there to support you and can handle your laundry, meal preparation, errands and any other household tasks. Focus your energy on recommended therapy exercises, activities and caloric intake. Don’t be concerned if you need more help than you expected.
  • Mild Independence.When you feel stronger, you should ask your caregiver to cut back on hands-on care whenever possible. Identify tasks that you can now manage independently, such as eating or walking down the stairs, and slowly wean yourself off of care in these areas. Never compromise your safety; ask your caregiver to step in if you feel uncomfortable.
  • Supervised Independence.Over time, you should gradually increase your independence. Your caregiver should be there to assist if needed, but the caregiver’s primary role should be supervision and safety monitoring rather than direct physical assistance. Try to perform the activities of daily living – bathing, dressing, grooming, eating, walking – as independently as possible.
  • Supported Independence.Once you are comfortable with the activities of daily living, you can incorporate chores and other housework into your routine. Try a trip to the grocery store or the pharmacy accompanied by your caregiver, or join in to prepare a meal together. Though these steps may seem minor and incremental, they are important touchstones in your path toward a full recovery.
  • Reaching Independence.In this phase, you should try to take responsibility for day-to-day tasks and return to your pre-hospitalization routine. Just remember, your caregiver is there to assist you if you need help. Some activities may be more difficult following a rehabilitation stay, regardless of the progress in your recovery. Remember that full independence is a long-term goal and should not be prioritized ahead of your safety.

Transition Home™ Package

Home Care Assistance’s Transition Home™ Package helps families manage the discharge process, provides a seamless transition home and promotes effective rehabilitation at home. The package includes:

  • A consultation and personalized Care Plan developed over the telephone or in person, based on your preference.
  • An expertly trained caregiver who will meet you and your family in the facility or at home to support the critical initial transition.
  • Support with home safety needs, including recommendations about equipment and home safety modifications to support your recovery.
  • Ongoing support with errands, grocery shopping, prescription pick-up, housekeeping and other physical activities that may be too challenging for a recently discharged patient.
  • Physical assistance with activities of daily living including mobility, bathing and grooming, eating and transferring tailored to the patient’s needs.
  • Meal preparation based on our proprietary Balanced Care Method™ with an emphasis on healthy, balanced nutrition and regular caloric intake in line with the physician’s recommendations.
  • Medication reminders, rehabilitation exercise prompts, physical and emotional support and companionship throughout the recovery process.
  • Transportation to rehabilitation sessions, doctor appointments and personal events.
  • Regular status updates from the care team, at your discretion, to designated family and friends.

The first 72 hours at home are critical for post-rehabilitation patients. The patient and family must make lifestyle adjustments no matter how comprehensive the discharge plan may be. The patient often feels fatigued and family members can feel confused or helpless. Our caregivers are here to help manage the transition and help you on the path toward a successful recovery in the comfort of home.