Safe Transition Home

The Care Team

The care team will assess your or your family member’s progress toward a safe transition to your home/community every week and keep you updated on your progress. You or your family member is transitioned/discharged from skilled rehab when the physician and care team determine that you have reached safe goals for return to the community or you require extended services at another level of care. When a projected date for discharge has been set, we will discuss this with you and/or your family member.

Please speak up and let the team know if you feel you or your family member is not ready for discharge.

When You or Your Family Member Cannot Go Home

Although our goal may be for you or your family member to go home or return to your previous setting in the community, this is not always possible. The recommendation for a safe transition to another setting will be reviewed by the care team with you and your family. The social worker will be available to discuss resources and alternative settings. This kind of safe transition requires planning and careful consideration of your or your family member’s needs and situation.

Rehab After Discharge

Many patients continue their rehab after returning home or to the community. This can happen at home (home health) or in the community (outpatient therapy).