Preparing for Your Return Home

Discharge Planning:
Discharge planning begins on the day you arrive. Your case manager discusses the discharge process with you and your family. This information assists you in preparing for where you will go and your needs after discharge. Each member of your team directs the plan of care toward discharge. Our goal is to prepare you to go back home to the community.

The case manager will communicate with you and your family individually to review discharge needs and plans. The rehab team will meet with you and your family members for a family conference as necessary. The case manager and doctor will discuss final reports on your progress and answer your questions. Upon discharge, you will be given information such as, appointments with the doctor(s), outpatient therapy, homecare, medication(s), and diet.

Home Pass:
One way we encourage you to prepare for your discharge is the home pass. The pass is a trial run to see how things go at home and in the community. This should decrease the number of surprises you may have, and help you manage the unavoidable ones. Passes are granted based on the doctor's approval. Home passes also depend upon your insurance coverage. Training in the areas of mobility, ADLs, medical issues, medicine management and special needs must be completed prior to use of the pass. You and whoever will accompany you on your pass will need to show the treatment team that these areas can be managed safely. Training must be done with each of your therapists and your nurse. The team will let your doctor know what training has been completed. The doctor will then write a pass if it is appropriate. Home passes are available for up to 6 hours during the day, usually on weekends.

ADL Apartment (Activities of Daily Living Apartment)
At our Rockville location, we have an ADL Apartment located on the first floor in the outpatient therapy gym. This is a completely furnished apartment that is used as a trial run, before going home. This gives patients the opportunity to try being on their own, with the security of our staff right up stairs. The ADL Apartment may be used for an overnight pass during the week or weekends.

Home Survey:
Before discharge, your family may be asked to complete a home survey. The survey is to be completed by your family and given to the therapist. The data is used by the doctor and therapists to suggest changes to make your home more accessible.

Family Training:
Your family will need to come to the hospital and spend time with you on one or more days. During this time, the staff will work with you and your family to be sure that you are ready for discharge. This allows you and your family to get comfortable with your needs. This is done through education and training provided by the staff. The case manager or therapist will notify you and your family to schedule training.

Customer Service and Follow-up Services:
A company called Press Gainey will be mailing a satisfaction survey to your home. Your feedback is critical to us as we strive to continuously improve our services. Please complete the survey and return it as soon as possible.

Another company called IT HealthTrack will contact you via phone three months following your discharge to see how you are doing. This call helps us to truly evaluate our outcomes by understanding how well your have sustained your rehabilitation goals.

If your doctor suggests therapy after discharge, you may be seen in Rockville at our outpatient department, at one of our other outpatient centers in Derwood or Silver Spring, or another site of your choice. The team will help you and your family locate a suitable site to continue therapy. A home exercise program or other educational materials may be provided to you upon discharge.