By Teresa Halverson, Director of Business Development/Community Relations
After a major medical event and a lengthy stay in an acute setting, seniors often are at a loss during the transition of care. This may include the breakdown in communication and coordination between the hospital, the patient/family, and the next care provider, directly leading to preventable readmissions. The senior/caregiver often is unaware of “red flag” symptoms of a worsening condition (i.e. fluid retention in heart failure) or when to call their physician verses 911. This often leads to delayed, inappropriate or overcautious care (i.e. an unnecessary ER visit).
The transition period, particularly the first 30 days post hospital discharge, is the most vulnerable time for seniors because they shift abruptly from 24/7 acute medical care to an often-fragmented system of self-management and family care. This period is often referred to as a state of “post-hospital syndrome,” where patients have depleted physiological reserves and are at high risk for new or worsening conditions. Some of these conditions may include:
- Deconditioning and Frailty: Even a short hospital stay can lead to significant muscle loss, weakness, and decline in mobility, making the senior highly susceptible to falls and subsequent injury upon returning home.
- Physiological Vulnerability: The stress of illness and hospitalization leaves the body’s immune system weakened, increasing the risk of new infections (like pneumonia or UTIs) or complications from the initial illness.
- Cognitive Decline: Hospitalization can often trigger or worsen confusion and delirium, which severely compromises a senior’s ability to understand and follow complex discharge instructions.
- Medication Chaos: Seniors are often discharged with an average of 3-5 new medication changes (new drugs, discontinued drugs, or dosage changes). Medication errors, a leading cause of readmission, are most likely to occur within the first 48 hours of being home.
Hospitals work diligently with senior care facilities and health care partners to ensure that seniors are discharged with confirmed plans for support (i.e. home health, skilled nursing and rehab facilities, medical equipment and transportation). If you are being discharged from acute care and require specialized follow-on care, it is important to know your options. A skilled nursing and rehab center relies on a variety of specialists to address the patient’s acute needs following hospitalization.
Going to post-acute rehab after a hospital stay is an essential step for many people because it bridges the gap between acute medical treatment and safely returning home. The primary goal of post-acute rehabilitation is to help you regain the strength, mobility, and skills you need to live independently, while also preventing complications that could land you back in the hospital. Your treatment plan is customized to your specific condition and goals, ensuring you make measurable progress towards independence.
Who is Post-Acute Rehab For?
Post-acute rehab is typically recommended if you:
- Need continued medical care that can’t be safely managed at home.
- Require multiple types of therapy (PT, OT, SLP).
- Have the physical and cognitive ability to tolerate intensive therapy and are motivated to participate.
- Are recovering from a major event like:
- Stroke or Brain Injury
- Major Orthopedic Surgery (e.g., hip or knee replacement)
- Major Illness (e.g., severe pneumonia, heart failure, prolonged critical illness)
- Major Trauma or Amputation
Your hospital care team (doctors, case managers, and therapists) will assess your condition and recommend the appropriate level of post-acute care for your needs. Reasons why post-acute rehab is highly beneficial:
Types of Medical & Rehabilitation Specialists
Medical Specialists (Consulting Physicians)
While the primary care physician (PCP) or medical director in a skilled nursing and rehabilitation facility oversees general medical care, specialists act as highly focused resources within the interdisciplinary team.
These physicians are typically consulted on an as-needed basis for specific conditions:
- Physiatrist (Rehabilitation Medicine Specialist): Directs the overall rehab program. They specialize in nerve, muscle, and bone injuries and aim to restore function lost due to injury or illness.
- Cardiologist: Manages conditions like Congestive Heart Failure (CHF) and post-heart attack recovery, adjusting medications and monitoring cardiac status.
- Pulmonologist: Treats respiratory issues such as Chronic Obstructive Pulmonary Disease (COPD) or pneumonia recovery, often managing oxygen therapy.
- Wound Care Specialist (Physician, Certified Nurse or Certified Therapist): Provides advanced care for non-healing ulcers, surgical wounds, or pressure injuries (bedsores).
- Neurologist: Manages patients recovering from stroke, Parkinson’s disease, or other neurological conditions.
Importance and Impact of Specialty Care
The specialized expertise is critical because patients in a skilled nursing facility are in a transition phase, requiring complex, time-sensitive care.
- Precision and Complexity Management: Specialists possess a deeper knowledge of high-risk, complex conditions (e.g., managing post-operative joint infection or fine-tuning diabetes control). Their involvement ensures the patient receives care that goes beyond general medicine.
- Optimizing Rehabilitation Outcomes: The Physiatrist and therapy specialists (PT, OT, SLP) create highly personalized, goal-oriented treatment plans. Their expertise is required to classify the service as “skilled” by Medicare, ensuring intensive, rapid functional improvement necessary for the patient to return home.
- Reducing Hospital Readmissions: The primary goal of SNF/Rehab is to prevent the patient’s condition from worsening and requiring a return to the hospital. Specialists help achieve this by:
- Early Detection: Catching subtle changes in a specific condition (e.g., a Cardiologist spotting signs of impending CHF exacerbation).
- Aggressive Management: Implementing swift, expert interventions for conditions like severe wounds or complex IV antibiotic protocols.
- Care Collaboration: Specialists communicate their findings and treatment directives to the facility’s interdisciplinary team (nurses, social workers, dietitians), ensuring all aspects of the patient’s care plan are integrated and coordinated
Transition to Home
Rehab is designed to prepare you for a safe discharge back to your home environment.
- Practice Daily Living Skills: Occupational therapists work with you to practice everyday tasks in a simulated home environment, teaching you how to manage stairs, get in and out of a shower, or prepare a meal safely with your current limitations.
- Equipment and Support Planning: The team (social worker/case manager) coordinates your transition, ordering necessary durable medical equipment (walkers, shower chairs, etc.) and arranging for follow-up services like home health or outpatient therapy.
- Family Training: The rehab team can train your family members or caregivers on how to safely assist you once you get home, ensuring continuity of care.
The Manor at Blue Water Bay, a skilled nursing and rehabilitation facility, offers a range of high-level specialized services that include neurology, wound care and physiatrist consultations. These specialized physicians work with the patient’s primary care physician, medical director and our interdisciplinary care team to ensure the best possible outcomes. For additional information and a tour, please contact us at 850-897-5592 or email: wecare@manoratbwb.com.
www.manoratbwb.com, The Manor at Blue Water Bay, 1500 N. White Point Road, Niceville, FL 32578
