Transitioning Home

From your first day of admission, our nursing and rehabilitation team begins to customize a plan, unique to your needs, so that you are ready for the challenges involved with returning home or to an alternate level of care. Working with our case manager/social worker, we will arrange for wheelchair, walkers, dietary needs, wound care, and/or medication management; in addition to patient education needed to ensure a safe transition home. In addition, we offer a continuity of care with our Home Health Agency Stay Well Home Health.

Helpful tips for a successful transition home:

Be an active presence in the discharge planning process.
Make sure you understand why your loved one was in the hospital.
Plan to provide extra help and support to your loved one during the recovery period.
Understand what symptoms and signs your loved one should be monitored for, and who to call if you have concerns.
Make sure the discharge instructions are clear regarding medications - make sure you take the medications as they're prescribed on discharge from the skilled nursing facility.
Prepare the home for your loved one's recovery.
Understand what home health services will be provided.
Make sure follow-up has been arranged with a primary care doctor or other outpatient health provider.
Understand your symptoms so you know when to call the doctor or go to the hospital.
- Do you have increased shortness of breath?
- Swelling in your feet, ankles, legs, arms or stomach?
- Are you experiencing any chest pain?
Consider calling your doctor if you feel or notice the following:
- New, more, or worse dry coughing
- More shortness of breath
- New dizziness
- No energy; more tired than usual
- Increased pain/discomfort
- Any unusual feeling