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Discharge Planning

Discharge planning is an important part of the rehabilitation program and starts when you are admitted to the unit. As you progress towards discharge, the social worker/program coordinator will discuss the recommendations made by the rehab team for expected care needed when you leave the rehab unit. The options that exist for this care, your preferences, and financial considerations will be reviewed with you and your family. An estimated discharge date is typically set by the rehab team within the first week and will be discussed with you and your family. The social worker/program coordinator will also assist in making contacts to agencies, facilities, or equipment providers who will be involved in your care when you leave the rehabilitation unity. One goal of rehab is to help you gain the highest level of independence. When you are ready to be discharged, the team will assist you in making a positive transition.

Care Conferences

Care conferences are held on Tuesdays and Thursdays. The Tuesday care conference is held with the rehab team itself, discussing each of our patients progress, goals, and barriers to functional living. The social worker will provide the patient and family updates after this meeting.

On Thursdays the rehab team will hold a weekly bedside care conference over the noon hour. On these days lunch will be served in your room. The rehab team will meet with each patient and family for 5 minutes to discuss goals, progress, plans for discharge, and estimated length of stay. We welcome you to write questions or comments down that we can address for you during the meeting.

If more time is needed than 5 minutes to answer questions we will work with you to set up a family meeting to accommodate all questions and comments.

Home Evaluations

A home evaluation may also be completed prior to your discharge. The therapist will accompany you to your home and will have you demonstrate your skills in your environment. This will give you, your caregiver, and your rehabilitation team an opportunity to suggest any changes that could help improve independence or identify skills that need improvement.

Apartment Stay

During your stay, you and the rehab team will determine if you should move into our transitional apartment. This is usually done 2 -3 days before discharge. This apartment-like setting is where you and your family can practice living skills in a safe environment. If difficulties were experienced, the rehabilitation staff would be available for assistance.