Being hospitalized is usually an unexpected and overwhelming process. Patients and their families often expect to return home once they are stable and their medical team feels they can be discharged. Unfortunately, patients hospitalized due to complex illness, trauma, or surgery can become debilitated during their time in the hospital. This can also include unexpected outcomes from serious events, such as a heart attack, stroke, brain injury, or spinal cord injury. While some patients may be able to get right back home and resume their valued daily activities, rehabilitation for body and mind is often required.

At discharge from the hospital, a patient no longer requires an acute level of care, meaning they do not require around-the-clock medical observation and care. However, a patient may still require more care than they would have at home. There are several factors to consider when determining a patient’s post-hospital needs, including:

  • A patient’s ability to care for themselves, safely access their home, and ability to be alone at home.
  • Ongoing complex medical needs, including IV medications, wound care, and heavy physical assistance.
  • Loss of function and independence from illness or injury, necessitating ongoing physical therapy (PT), occupational therapy (OT), speech and language therapy (ST), rehabilitation medicine, and use of prosthetics or orthotics.

For patients who meet certain criteria, they may require an inpatient rehabilitation facility, a skilled nursing facility, or skilled care at home.

Acute or Inpatient Rehabilitation Facilities

These facilities are often called “acute rehab,” a “rehab unit,” or “inpatient rehab.” They may be in a freestanding hospital, or a rehabilitation unit within a general medical hospital. The patients seen in these settings typically require close medical oversight, therapies from multiple disciplines, and rehabilitation efforts are more intensive and individualized with a focus on a faster return home.

All patients are provided with at least three hours of skilled therapy services per day, at least five days per week, to include: physical therapy, occupational therapy, or speech and language therapy. Patients are still in a hospital setting, which includes daily medical oversight from a hospitalist, and consulting physicians as needed (neurology, surgery, orthopedics, etc.).

Inpatient rehab facilities are led by physiatrists, who are physicians with board certification in physical medicine & rehabilitation. Each patient is assigned a physiatrist who is skilled at guiding their rehab recovery. These facilities also offer more individualized care: nearly all patient therapy sessions are one-on-one with the therapist, and the patient’s interdisciplinary care team holds weekly meetings to make sure their goals of care and individual needs are being met.

As part of the Lifespan system, the Vanderbilt Rehabilitation Center at Newport Hospital provides great benefits to patients and the continuity of their care. Our rehab physicians, nurses, and therapists have full access to the patient’s prior medical record from their hospitalization, which greatly minimizes any miscommunication.

Our physicians can easily communicate a patient’s progress to Lifespan specialists and adjust their plan of care during rehab, reducing the need for multiple appointments while recovering. We have made significant investments in the latest rehab technologies to maximize patient recovery. All patients are guaranteed to have a private room during their stay at the center.

Skilled Nursing Facilities

These are community facilities that often include “nursing and rehab” in their title. These facilities provide a “sub-acute” level of rehab for patients who want to return to their prior level of strength and function before illness or injury. Patients receive ongoing assistance from nursing for all mobility (walking, using a wheelchair) and all daily self-care activities (bathing, toileting, dressing).

Nurses can provide ongoing daily assistance for management of medications, wounds, IV lines, etc. Medical oversight is provided by a physician, however this occurs on a less frequent basis (sometimes weekly). Urgent medical needs require transfer to an emergency room and possible re-hospitalization. Patients receive skilled therapies (PT, OT, ST) usually about five days per week for one to two hours and may include therapy sessions in a group setting.

In-Home Care with Visiting Nurse Services

For many patients, the idea of being back in their own home is the most comforting after a stressful hospitalization. Depending upon insurance coverage, many patients qualify for visiting nurse services. This may include: a registered nurse, qualifying therapies (PT/OT/ST), and possibly a home health aide.

Patients who may be suitable for in-home care and recovery would need to demonstrate the ability to safely access their home, navigate stairs, complete daily self-care activities (bathing, using the toilet), and have appropriate medical equipment set up (hospital bed, shower chair, ramps). If unable to complete these activities, they would require around-the-clock help from family or private pay nursing.

Things to know about visiting nurse services

  • Skilled services (if covered by your insurance) may not be available daily–the schedule or frequency may be unpredictable.
  • Caregivers should be prepared to provide daily medical care, including management of wounds and medications, with weekly oversight from a registered nurse.
  • Medical care is accessed through appointments with the patient’s primary care doctor, urgent care, or emergency room.
  • Therapy services are present in the home about two times per week on average, allowing for slow but steady progress.

Some patients may require more care than they would get at home. These patients could be unsafe if left alone due to physical or cognitive concerns. They may have become too weak, and caregivers cannot safely care for them around the clock . Patients who have experienced traumatic medical events such as a stroke, brain injury, or traumatic orthopedic injury need more time with intensive therapies to maximize their level of recovery. These patients would be discharged to a skilled nursing facility or inpatient rehabilitation facility.

Hospitalization is often abrupt and unexpected, and sometimes the choice for rehabilitation can be rushed and unclear. Speak with your medical team to ensure you or a loved one are being discharged to the appropriate setting. Rehabilitation may take several weeks to months but is an important investment in the recovery process.

Learn more about all of the comprehensive, patient focused rehabilitation care options that are available on the Lifespan Rehabilitation Services website. 

David Michael, MOT, OTR/L, CBIS

David Michael, MOT, OTR/L, CBIS

David Michael, MOT, OTR/L, CBIS, is an occupational therapist and Care Transformation Specialist at Newport Hospital. He previously was a team member at the Vanderbilt Rehabilitation Center.