Posted on March 19, 2021 by Elder Care Consultants, Inc.

At discharge, the patient is transported to the rehabilitation facility, typically by ambulance or wheelchair van unless the patient is being transferred from the hospital to their Inpatient Acute Rehabilitation. The staff must quickly begin the task of getting to know its new patient which may be simplified if the transfer is in-house.

When the patient arrives, nursing staff will have reviewed the patient’s current hospital records, but typically knows little about his/her other medical or social history. Once the patient has arrived, his/her medications are ordered according to the records sent from the hospital, some of which may have been changed during the hospitalization. Nursing staff will physically examine the patient and test the patient’s mental acuity. Both the physical and mental status exam can be stressful for the patient. The initial mental status exam may not reflect the resident’s true mental acuity, but rather reflect a reaction to the multiple transfers (home or residential facility, to hospital, to rehab).

Within 24 hours, the patient and records will also be examined by the staff physician or the physician’s nurse practitioner who can make medical and rehab recommendations. The rehab staff (PT, OT, ST) and dietician will also meet the patient to begin forming the initial treatment plan.

Patients may be confused by his/her new surroundings, staff, and routines. Staff will be wearing masks and other protective clothing, which can be further disorienting to the patient.

The task of getting to know the patient, particularly important medical history may be complicated by COVID precautions. Some patients may be unable to provide much information about his/her medical history, medication regimen, or even dietary preferences.

Sub-Acute Rehabilitation and Acute Inpatient Rehabilitation staff work hard to provide care to patients who are COVID positive or are ill with COVID-19 and to keep the rest of the residents and staff safe. There are significant differences in how facilities manage this care. Some facilities will not accept COVID positive patients while others segregate them from the rest of the residents. Providing quality care and rehabilitation to all residents has become a challenge.

The impact of the lack of contact with the familiar faces and voices of loved ones cannot be underestimated. Residents feel lonely, confused, and sometimes depressed. These emotional states can negatively impact rehabilitation, appetite, and ultimately the patient’s recovery.

How are we helping patients and families? It is important for rehab staff to gain as accurate a picture of the patient as possible. By coordinating with families and the community physicians even prior to transfer to the rehab, we are able to work closely with nursing, rehab, and social work staff and their assistants to help them get to know the patient more fully and accurately from early in the rehab stay. How well was the patient functioning prior to the hospitalization? Where was he/she living and where would he/she likely live at the end of the rehab stay.

We can be in the best position to advocate for the most optimal rehab goals and outcome. When appropriate, we can advocate for more rehab sessions or more frequent treatment plan reviews. We also work with families and residents to bridge the physical distance by using various technologies to communicate and see one another, helping to mitigate the impact of the separation. We then work with patients and families as they look forward to the day rehab at the facility ends and a plan for future care is put into place.

Be sure to read Part I on In-Patient Acute Rehabilitation vs. Sub-Acute Rehabilitation and Part II on Hospital Discharge Process to Inpatient Acute Rehabilitation or Sub-Acute Rehabilitation.