Recovery is a long-term process, rarely completed by the time a patient is discharged. Many patients will require 24-hour supervision at the time of discharge. Your family should begin to plan for this immediately. A specific discharge plan is developed for the individual through discussion with the treatment team, the family, the insurer and, when possible, the patient.
Your social worker and training coordinator will organize the different aspects of the discharge plan in close cooperation with family members. Discharge planning begins at the time of admission and continues throughout the patient’s stay, incorporating such elements as family training, arranging appropriate therapies and securing recommended equipment for the home.
Depending upon your family member’s needs, further therapy sessions may be recommended following discharge. These services may include physical therapy, occupational therapy, speech therapy, nursing and/or social work and will be determined upon the needs of the patient and in accordance with insurance guidelines.
Home care may include physical, occupational and speech therapists: nurses: social workers and aides to come to the patient’s home to continue the rehabilitation process. Patients who receive home care therapy are generally recognized as being “home-bound” or physically unable to leave their homes. The treatment team will determine and recommend services, which are medically necessary.
The home care therapists generally come to the home three times per week depending on the patient’s needs. The duration of home care therapy depends on the patient’s level of progress and the home care staff will determine discharge from therapy services or referral for outpatient therapy services.
After completing intensive acute rehabilitation, a patient may require
continued therapy before returning home. It may then be suggested that
the patient continue therapy in a subacute setting. This recommendation
is not indicative of failure to progress in the acute rehabilitation
process: it simply enables the patient to continue daily physical,
occupational and speech therapy at a lesser intensity and for an
extended period of time, generally two to four weeks. This period of
continued therapy is vital for some patients to continue the healing
process and subacute placement serves as a bridge to their return home.
For those patients who are discharged home and are not “home-bound,” or those who have completed home care therapy and require continued intervention, outpatient therapy is frequently recommended. Outpatient therapy typically takes place three times per week and the patient is seen for each recommended therapy for up to an hour. Outpatient therapy is available at Sinai Hospital or at other centers in the area.
Many patients who return home after discharge require the services of outpatient day-treatment programs. This program is designed for those patients who continue to have physical, perceptual, cognitive-linguistic, speech-language and/or behavioral deficits but are planning to return to work or independent living.
Sinai’s outpatient RETURN! program
operates five days a week and includes individual and group treatment sessions beginning at 9:00 a.m. and ending at 3:00 p.m.