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The Older Adult’s Long Road Home from the Hospital

When older adults go to the hospital, the transition back home is often not as smooth as it is for younger adults.  In this article, we’ll discuss exactly what that process might look like.  Keep in mind that the ultimate goal is to eventually get the older adult safely back in their home, but sometimes it takes weeks or months to get there.  Read on and we’ll detail each possible step in the older adult’s long road home from the hospital.


After an injury or illness, older adults are often temporarily unable to return home.  If they have potential for improvement then there are several options for short term care.  These options are intended to get the person back to the level that the can eventually return home.


Inpatient rehab vs. Skilled nursing

Have you heard of an  inpatient rehab facility or a skilled nursing facility?  These terms get confusing because in the hospital they are generally both lumped into the term “rehab.”  It is not uncommon for the doctors, therapists, and nurses to say “you need to go to rehab.”  Technically inpatient rehab and skilled nursing are different.  Let’s discuss the differences.


Inpatient Rehab

  • This type of facility offers nursing care but has a primary focus on therapy services.  Inpatient rehab requires patients to participate in 3 hours of therapy per day.  Therapy can include physical therapy, occupational therapy, and speech therapy depending on what each patient needs.  There is some overlap between each type of therapy, but I’ve highlighted some of the main differences below.
    • Physical therapy focuses on strength, endurance, balance, cardiovascular performance, walking, stair climbing, getting in and out of bed/chairs/vehicles, etc.
    • Occupational therapy focuses on one’s ability to perform daily tasks like dressing, bathing, managing medications, preparing meals, and performing grooming and hygiene tasks.
    • Speech therapy focuses on swallowing, speaking, listening, reading, writing, and thinking.
  • The average amount of time that people stay at an inpatient rehab facility is roughly 10 days, but that varies depending on diagnosis and functional limitations.
  • Medicare pays for inpatient rehab under 3 conditions.
    1.   The patient has a qualifying diagnosis.
    2.   They are meeting the 3 hour daily requirement for therapy.
    3.   They are continuing to make measurable, functional improvement.


Skilled Nursing

  • This type of facility offers nursing care as well as daily therapy services.  Patients typically receive 1-2 hours of therapy per day.  Just like in rehab, therapy could include physical, occupational, and speech.
  • The average length of stay in a skilled nursing unit is roughly 2 weeks to 2 months.
  • Medicare pays for skilled nursing after a patient has spent 3 midnights in the hospital.  If someone is not able to go to inpatient rehab due to lack of a qualifying diagnosis or an inability to tolerate 3 hours per day of therapy then skilled nursing is likely the best option.  If they have not had 3 overnight stays in the hospital, then skilled nursing services can be paid for out of pocket.  Warning: it is very expensive!  We’re talking several hundred dollars per day.


Home Health vs. Outpatient Therapy

If older adults are admitted to the hospital, but they do not necessarily need inpatient rehab or skilled nursing then there are still a couple more options: namely  home health therapy or outpatient therapy.  Both of these options allow the person to go home from the hospital while getting some continued care in order improve their safety and independence.  Home health or outpatient therapy are appropriate for people that are generally safe at home even with their continued deficits-OR-they have the help they need from family members or caregivers to keep them safe while their own safety and independence continue to improve.  Let’s discuss the differences between home health and outpatient therapy.


Home Health

  • This service could involve a nurse, a physical therapist, an occupational therapist, a speech therapist, and a bath aide.  Each person works with the patient in the patient’s home.
  • A nurse will be involved if there is a need for oversight of medical issues like medications, vital signs, or wounds.
  • A bath aide assists with bathing if the occupational therapist identifies that the patient needs assistance with that daily task.
  • The physical, occupational, and speech therapists will work on the items outlined in the inpatient rehab section above.  They will also go through the patient’s home and make suggestions for home modifications to improve safety.
  • Home health therapy is only for people that are “homebound.”  Medicare’s definition of homebound means meeting one of these 2 criteria:
    • You need the help of another person or medical equipment such as crutches, a walker, or a wheelchair to leave your home.
    • Your doctor believes that your health or illness could get worse if you leave your home.
  • Home health (if it is medically necessary) is paid for by Medicare, but there is a cap to the amount that they’ll pay each year.
  • Home health usually lasts for 1 to 4 weeks, and each therapist comes over 2-3 times per week for 30-45 minutes.  The nurse and bath aide may come less frequently.
  • Once the patient has met their goals or they are no longer home bound, then home health therapy ends.


Outpatient Therapy

  • When a person is no longer homebound, but they still have potential for some functional improvement, outpatient therapy is appropriate.  This type of therapy takes place in an outpatient clinic or in the outpatient department of a hospital.  Physical, occupational, or speech therapy can all be offered on an outpatient basis.
  • Outpatient therapy appointments are generally scheduled 1-3 times per week.  Sometimes outpatient therapy goes on for months depending on individual needs and continued progress.
  • Outpatient therapy (if it’s medically necessary) is paid for by Medicare, but there is a cap to the amount that they’ll pay each year.


Real Life Examples

Let’s discuss some scenarios in which someone would participate in one or more of the above options.


Home Health + Outpatient therapy

Stan is a 72 year old man who recently had his left knee replaced.  He lives alone in a split level home with 6 stairs to get in.  He spent 2 days in the hospital after his knee surgery.  He worked with physical and occupational therapy during his hospital stay.  Stan needs a walker, he can only walk about 50 feet at a time, and he needs physical assistance to get up and down the stairs.  He’s also having a lot of pain as well as some drainage from his knee incision.  Stan’s daughter is in town and can stay with him for the next week.


In this case, Stan would be a good candidate for home health therapy with the plan to transition to outpatient therapy as soon as possible.  Home health therapy would likely include a nurse to monitor his incision and his pain management.  Physical therapy would assist with improving his knee flexibility and strength, his ability to walk in his home, and his safety on the stairs.  Occupational therapy (and possibly a bath aide) might be involved if Stan is having trouble with dressing himself, bathing, or standing long enough to prepare a meal for himself.


Once Stan is no longer homebound (in a week or two), he will start outpatient physical therapy.  There he’ll work more on his knee flexibility and strength, and he’ll work toward resuming his previous activity level.  This may take 2 months or more.


Skilled Nursing or Inpatient Rehab + Home Health + Outpatient therapy

Now let’s imagine that on top of his recent knee replacement, Stan also has Parkinson’s.  Plus he had multiple near falls in the hospital….  His daughter lives across the country so she won’t be able to help.


This case just got a lot more complicated!  Stan can’t get himself in and out of his house safely so discharging home alone is not an option.  He will need inpatient rehab or skilled nursing prior to returning home.   If he’s capable of returning home after a few weeks of intensive physical and occupational therapy, then he still could go through the process of home health and then outpatient therapy.


Outpatient Therapy only

Finally, let’s say that Stan did great with his therapy in the hospital.  He can get up and down the stairs on his own, he can get in and out of the passenger seat of his car with ease, and he’s able to walk several hundred feet with his walker.

Now Stan can skip everything else and go straight to outpatient physical therapy within a couple days of returning home.  He’ll have to arrange for a ride as he likely won’t be able to drive.  Otherwise he’s good to go.


I hope you’ve found this article to be helpful for figuring out what to expect after a hospital stay.  Illness, injuries, and surgeries that require hospitalization often make for a long road home.  That road will be slightly less scary and frustrating if you know what to expect.


P.s.  When an older adult first returns home after a hospital, rehab, or skilled nursing stay, there are several ways that you can make their transition back home a little easier.  Click here for more details.  


I’ll leave you with one last thing. When transitioning from home -> hospital -> inpatient rehab -> home with home health -> outpatient therapy, several of the same questions will be asked dozens (if not hundreds) of times. And lot’s of important details will be lost in translation. I’ve created this downloadable hospital form for instances just like this. Once you fill it out, you’ll have a master copy that documents your past medical history, your medications, your home setup, and your previous level of activity. You can make updates as needed. I firmly believe that if you use this form then your hospital stay and all the subsequent events after that will be safer, less stressful, and less annoying.


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