Case Study: A Safe Rehab Discharge After Falls

Getting mom home safely after rehab discharge

Often when loved ones are in rehab, a family will get a call out of the blue ‘She’s being discharged tomorrow.’

No warning. No instructions. They wonder, what do I need do to prepare for a rehab discharge? That is when the panic sets in.

Who will care for her every day? Is the right equipment in place? Is the house even safe for someone who cannot move the way she used to?

 Most families have no one lined up and no plan ready. It is one of the hardest moments in caregiving, and it arrives fast.

This is the wall MK’s family hit. MK is in her 90s. After a series of falls, she went to the hospital, then to a rehabilitation facility. She wanted one thing next: to go home and stay there safely. Her family wanted that too. They just did not know how to make it happen.

MK also lives with neuropathy, a nerve condition that affects balance and can leave the feet numb and unsteady. Every time she stood up, she risked another fall. Some of the family worked full time. Some lived out of state. No one could be with her at all time. Her care had also grown complicated. Multiple providers. Many appointments. Different settings, each with its own instructions.

So they brought in Umbra advocate Victoria de la Cruz. Victoria has walked families through this many times. She has more than 15 years in home health care management and senior care coordination, and she knew what to put in place. She took the case with one focus: get MK home, make home safe, and take the panic off the family.

Building the rehab discharge plan to get home

Victoria worked with the hospital and rehab teams so the discharge plan pointed toward home, not another facility. She joined the discharge planning meeting, read the care plan line by line, and pushed on the gaps. She held the case manager and social worker accountable for arranging for transport back home and a walker.

Setting up the home for recovery after rehab

A safe rehab discharge is only the start. MK needed the right care waiting for her. Victoria arranged it:

• Skilled nursing to monitor her health and manage her medications.
• Physical therapy to rebuild her strength and steady her walking.
• Occupational therapy to help her handle daily tasks again, like dressing and bathing.
• A home health aide for hands on help on the days he family couldn’t be there.

She also made the house safer. She arranged grab bars in the bathroom, cleared loose rugs from the walkways, and set up a bed on the first floor so MK would not climb stairs while she healed. She organized the medications so the family could keep them straight, and confirmed the walker and other equipment arrived before MK did.

Then she kept the family informed at every step, in plain language, so no one was left guessing.

A successful return to home from the hospital

MK went home. She recovered in her own house and rebuilt her strength and independence. Within weeks she was moving with her walker on her own. Her family understood the plan and knew what to watch for. The dread that comes with a discharge date turned into something they could handle.

“Every senior deserves someone advocating for them, helping them navigate the system, and making sure their wishes are heard.” — Victoria de la Cruz, Umbra Patient Advocate

Heading home after a hospital or rehab stay?

You do not have to coordinate it alone. An Umbra advocate can work with your care team on a safe discharge, arrange skilled nursing and therapy at home, set up the home for recovery, and keep your family clear on every step.

Call us at 332-699-6778 or tell us more about your situation.