What happens after acute care?
Discharge planning
Early in the hospital stay, the social worker will meet with the patient and family to start discharge planning. Many patients will need care or therapy after they leave acute care. Some patients will be discharged to a nursing facility, while others will be discharged to their homes.
Discharge to a nursing facility
There are several types of nursing facilities.
Skilled care
Skilled care provides extensive nursing care and daily therapy. Many patients will start with skilled care and then move to acute rehabilitation care, intermediate care, or residential care.
Acute rehabilitation
Acute rehabilitation provides an inpatient program of intense therapy in a hospital. The patient will need to actively participate in three to six hours of therapy per day (i.e. physical, occupational, speech, and activity therapy).
Intermediate care
Intermediate care provides less extensive nursing care and therapy.
Residential care
Residential care is for patients who are fairly independent and do not need routine nursing care or therapies.
Discharge to home
If the patient goes home, they may still need therapy or other care. Some of the options are:
Outpatient therapy
Outpatient therapy is provided at hospitals, clinics and some nursing homes. Outpatient physical therapy will help build up strength and endurance. Outpatient occupational, speech and cognitive therapy may also be needed. Family or friends may need to arrange transportation for therapy appointments.
Home health care
Home health care programs are available in many communities. Some of the services they offer include in-home nursing care, homemaker and health aides, meals-on-wheels, adult day care, home therapy visits, medical equipment rental/purchase, and transportation.
Making the choice
During the acute care hospital stay, the health care team will make recommendations about the level of care the patient will need at discharge. Then the patient and family will choose the agency that provides the services. Your choice may be based on insurance coverage, location, the patient's potential for recovery, and the patient’s or family's feelings about the services provided. Some facilities will come to the hospital to see the patient and their medical record before they decide to accept the patient. If accepted, the date for transfer or discharge will be set.