What to Expect Upon Discharge from a Skilled Nursing Facility?

Contributed by Michelle Russo, Executive Director, Harlee Manor Nursing & Rehab Center, Springfield Senior Commons Assisted Living

Many seniors find themselves in a skilled nursing facility following a hospitalization. The goal of this extended stay is to provide the patient with additional rehabilitation to prepare them for their return home. The therapy may focus on increasing strength and endurance, ensuring safety awareness, and training the patient and family as needed to manage the patient’s very specific needs. However, the rehabilitation does not end when the individual is discharged from the skilled nursing facility.

Upon discharge from the skilled nursing facility the patient and family will be provided with written discharge instructions. The facility will identify and order any necessary equipment needs that the individual may have. This equipment will either be delivered to the nursing facility and/or directly to the patient’s home. In some circumstances the patient’s home may require modifications to accommodate their physical needs. For example, a doorway in the home may need to be widened to allow a wheelchair to pass through.

The nursing facility will make a referral to a Home Health Agency. Within 48 hours of returning to home, the patient will be visited by a representative of the Home Health Agency to evaluate the individual and open the case. A plan of care will be developed by the Home Health Agency that will provide the necessary therapy services, nursing if indicated, and possibly home visits by a Home Health Aide.

It is imperative that the patient and family understand that Home Health services do not provide around the clock care. These services are also not offered indefinitely. If an individual requires more assistance, this must come from family members and/or privately hired personnel. There are an abundance of agencies that offer nursing aides and companions for a set fee. Emergency Response Systems are also an excellent way to assist an elderly person. These systems allow the individual to call for help in serious situations by pressing a button that is linked to a control center.

Everyone should acquaint themselves with community based services as well as programs offered through the state of Pennsylvania. The Delaware County Office of Services for the Aging (COSA) offers Adult Day Services, Care Management, Home Delivered Meals, and In-Home Services to name a few. Assistance with prescriptions is available through PACE and PACENET, and Community Transit provides specialized transportation to older adults aged 65 and over. Please note that there are eligibility guidelines that must be met in regards to medical condition and income. We encourage seniors and/or their family members to contact COSA at (610) 490-1300 or visit their website at www.delcosa.org.