Guiding a Patient after Hospital Discharge: How to Navigate Rehab and Home Health Aid

Our Patients Rising Concierge navigator program is an online, phone and email support service for patients and caregivers. Our professional patient navigators provide direct support to people and connect them to local, state and national resources, programs, and services.

Each week, we highlight patient challenges and how we helped.

Client Situation: Patient just got out of the hospital after a month being inpatient. The patient needs rehab and a home health aide while recovering. While the patient is glad to be home, the next steps in recovery were not clearly given to the patient. The family isn’t sure what to do, how to get help, or even where to start.

PRC Response: While this situation doesn’t have an easy resource to share, my recommendation was: 

  • Start with the discharge papers; check to see if there are notes, a prescription, or any information from the discharging doctor and medical team. If there’s no info there… 
  • The primary care physician (PCP) would be the next place to reach out to. Most physicians require a PCP visit post-discharge. Hospitals don’t generally provide follow up care and leave that to the patient’s normal medical team.

Additionally, the patient may be able to get home health covered, depending on their insurance. It’s expensive out of pocket, so it’s important to have the doctor help with that situation. Insurance may dictate which home health company is used, but that can mean they will pay the cost; or at the very least a portion of it.

In conclusion, this is where having an open line of communication with your medical team is important. When in a difficult medical situation, you need medical professionals who can help you navigate the individual situation, which all starts with communication.



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