Preparing for Your Return Home - Adventist HealthCare

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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 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.

On the day of discharge, you will be given a green folder with information regarding your discharge instructions and follow-up care such as, appointments with the doctor(s), outpatient therapy, homecare, medication(s), and diet. Discharge time is between 10am and 12noon. The rehab team will make every effort to get your care arranged in advance so you can leave during that time.

W.I.N.! (What I Need)

To aid your case manager in determining which resources may be appropriate for your potential discharge needs, please take a few moments to review the W.I.N.! (What I Need) resources listed below. A complete list is in your welcome folder. Your case manager will meet with you to assess your potential needs.

__ Adult Day Care __ Food Delivery
__ Driving Program __ Vocational Rehab
__ Equipment Resources __ Disability Parking Application
__ Prescription Assistance __ Psychotherapy
__ Personal Alarm __ Transportation
__ Assisted Living Facilities/Group Homes __ Moving Resources
__ Rental & Utility Assistance __ Home Health Assistance
__ Private Pay Aide Services

Therapeutic Leave Pass

One way we encourage you to prepare for your discharge is the therapeutic leave pass. The pass is a trial run to see how things go at home and in the community to practice skills you have learned. 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, activities of daily living, medical issues, medication management and special needs must be completed with your family/support team 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, so as to not interfere with scheduled therapies during the week.

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. We have converted a room into an ADL apartment at our Takoma Park location. This is an apartment that is used as a trial run, before going home. This gives you the opportunity to try being on your own, with the security of our staff readily available. The ADL Apartment may be used during the week or weekends, once it is deemed safe and appropriate by the team. When this trial run has been completed, the team can then discuss or review anything found difficult or challenging by you and your support team. We encourage a family member or member of your support team to stay the night with you.

Home Assessment

Before discharge, your family may be asked to complete a home assessment. The assessment is to be completed by you and your family and given to the occupational therapist. The information is used by the therapists to suggest changes to make your home more accessible and manageable given your current strengths and limitations. Many accommodations and modifications include the installation of grab bars, hand-held shower heads or in some cases a ramp at the front entrance of your home.

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 how to safely manage 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.

Follow-up Services

If your doctor or therapist recommends therapy after discharge, you may be seen in Rockville at our outpatient department, at our outpatient center in 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. If it is unsafe for you to leave your home, you may be a candidate for home therapy.

Support Groups

We have a number of very active community-based support groups offered at Rockville: Al-Anon, Amputee, Brain Injury, Stroke and Spinal Cord Injury. For details of dates and times please ask your social worker or review the list in your discharge folder.

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