After a fall, a stroke, or a joint replacement, many older adults leave the hospital for a short stay in a skilled nursing facility for rehab. Families often focus on the first move, out of the hospital, and assume the rehab facility will handle the rest. Then a discharge date arrives with a few days’ notice, and the family has to get the house, the schedule, and the equipment ready at once.
This guide is for families whose parent is in rehab now, or about to go.
Ask about the hospital stay before rehab
Medicare’s rules for covering a stay in a skilled nursing facility depend on how the hospital stay was classified. Original Medicare Part A covers this care only after an inpatient hospital stay of at least three days in a row. Time spent in the hospital under “observation” does not count as inpatient, even overnight (Medicare Rights Center). Many Medicare Advantage plans waive the three-day requirement. Ask the hospital case manager whether the stay is inpatient or observation, and ask the plan what it will cover.
Use the rehab weeks to prepare the house
The weeks in rehab are the best time to get ready:
Ask the therapists what the person will be able to do at discharge, and what help they will still need
Ask whether a therapist can review the home layout, or what changes the therapists recommend
Arrange equipment early: a shower chair, grab bars, a raised toilet seat, a walker, a hospital bed if needed
Clear walking paths and improve lighting
OPA’s free Home Safety Walkthrough worksheet covers each room.
Ask for the discharge plan in writing
Before discharge from rehab, ask the facility for:
The discharge date and time, as early as possible
Medication changes since the hospital
Orders for home health visits, if the person will receive them
Exercises and safety limits from the therapists
Who to call with questions after the person gets home
OPA’s free Discharge Day worksheet turns these into a one-page handoff.
Plan the first week home
The first days home often need more help than the family expects, especially at night and during bathing. Plan who will be there, hour by hour, for the first week. OPA’s guide to the first week home after a hospital stay walks through it.
A first step this week
Call the rehab facility’s social worker or case manager and ask for an expected discharge date and a family meeting with the therapy team before that date.
If your parent will need help at home after rehab, see how care starts at OPA.
Medicare and plan rules change, and the coverage statements here were current Confirm current requirements before acting. Confirm coverage with Medicare, the person’s plan, or the hospital case manager. This is general information, not medical or legal advice.
