Preparing for Discharge

Ongoing services will most likely be needed after discharge from the rehabilitation unit to help achieve maximum potential. These services may include outpatient therapy, home health care, or skilled nursing facility services. Our social worker will do everything possible to discuss all options and assist in any way should an alternative setting be recommended.

Guidelines established by both Medicare and private insurance companies have placed limits on the amount of time a patient may be hospitalized; therefore, discharge plans will be discussed soon after admission and throughout the rehab stay.

Indicators Used to Determine Discharge

• The patient has met realistic goals established by the patient and the rehabilitation team.
• The patient requires only one rehabilitation service, such as physical therapy, occupational therapy, or speech therapy.
• There is evidence of failure to show improvement in function when progress is discussed by the rehab team.
• A complicating medical condition has developed which causes suspension of rehab therapy. Each patient will be discussed on a case by case basis by the rehab team for length of stay.
• The patient demonstrates non-compliance or failure to participate in their required rehab program of three hours of therapy a day, five days a week.
• Family demonstrates non-compliance or failure to participate in the rehab education program.
• The needs of the patient could best be served in an alternative setting (i.e., sub-acute, long-term care, or acute care setting.)