Rehab or Residential? Post-Hospitalization Care Decisions

We have all had to make decisions in life. Some decisions were easier than others, because the decision was of little significance. Making decisions about one’s senior years, or decisions for a loved one, is much harder. Post-hospitalization care decisions are some of the hardest decisions a person will have to make in their life.


We could ask rhetorically, which is harder, going in to the hospital or going out of it? In both situations a person is dealing with the unknown. “What will be?” is such an overwhelming thought-question.


Being honest, for a person who is reading this article, the decision may have been made already, at least for the time being. Brookhaven, Center for Rehabilitation and Healthcare, strives to give patients the best care, tailored to the patient’s specific needs.


Questions and Descisions

This article will focus on the decision-making process.

Getting your questions answered is very important, so here are a couple of resources on the subject:

Questions to ask at hospital discharge

John Hopkins – A guide to hospital discharge

Another very relevant topic is, the information that is needed about Medicare coverage.  In order for Medicare to cover a stay in a skilled nursing facility, the patient has to be admitted to a skilled nursing facility that is approved by Medicare within 30 days of leaving hospital. The hospital stay had to be at least 3 days in length.



Getting the Picture – What is needed after the Hospital

The big decision is about where the patient will go after being discharged.


Post-hospitalization care options are:

  1. Home
  2. The home of a friend or family member
  3. A skilled nursing facility (nursing home type)
  4. An assisted living community


The senior adult or the family who is making the decision have to:


  1. Understand the health factors that they are dealing with
  2. Understand the short-, medium-, and long-term consequences
  3. Know what resources they have
  4. Be very honest with themselves as to what they want and where they can compromise
  5. Be clear about what they can handle



The Decision-Making Factor

A large part of the decision will be decided by the medical team, who understand the medical condition of the patient and the prognosis.

The family and the senior adult themselves should know what important to them – and make sure to voice their opinions.

The truth is, that making post-hospitalization care decisions might not be a once-off occurrence.

A senior might be hospitalized more than once. A person might also choose to, or need to be moved to a different facility because their needs change.


Sarah Mitchell MSW says that the most important factor to take into account is:


  • Which senior living facility will reduce the need for hospital readmission?


The modern concept of telehealth can help in some cases, if patients choose to take a break from the nursing home or assisted living option.



What Are You Looking For? Your Preferred Options

A person wants to find a place that will be:


  • comfortable and liked by the senior themselves
  • approved by Medicare or whichever system will be used
  • provide enough therapy (frequency and variety) to optimize the patient’s recovery
  • nursing care at the highest standard, at the level the senior needs
  • emotional support and motivation for the senior, to succeed in the therapies
  • as convenient as possible for the family to visit



The View of Things in Hindsight

The next thing to think about is: How will the senior adult or the family look back on this decision after a few weeks, months or even years?


Making decisions should have these 2 elements:

  1. “I have faith in myself that I found out the best information I could in order to make this decision. I trust my ability to make a decision”
  2. Every decision can be fixed, if it needs tweaking.


A person should hopefully be able to say:


“I made the best decision that I could, I asked for the input of the medical staff, did my research, spoke, hoped and prayed. It is a good decision.”


“On hindsight, we made the best decision we could have. We made the best post-hospitalization care decision possible, with the knowledge and facilities we had available.”



Humanizing post-hospitalization care decisions is the best way, perhaps, to deal with the challenge. Real people are involved, not numerical factors. Every person involved in the decision-making process should retain their sensitivity and respect for all others involved.

Then, making those post-hospitalization care decisions may become a little easier.


post-hospitalization care decisions - can the senior still manage the stairs

Post-hospitalization care decisions include asking: Can the senior manage the stairs, when they go home after a medical event?

Photo by Jesse Roberts on Unsplash

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