From hospital to home

The road to recovery does not always end after a hospital stay. For some hospital patients, additional skilled care may still be needed before returning home.

Rehab to home, also known as “swing bed,” is a short-stay, hospital-based program for patients who no longer require inpatient hospital care but still need rehabilitation services or skilled nursing care before going home. The program ensures a smooth, safe transition home, helping patients reach their former level of independence.

Swing bed is a Medicare term that authorizes critical access hospitals (CAHs) in rural communities with 25 beds or fewer to offer the service. CAHs can “swing” between providing acute care and post-acute, skilled nursing facility-level care. Patients can transition from acute care to skilled nursing care within the same hospital, or to another hospital. Rehabilitation within a hospital is typically more intense than in a nursing home setting, offering more therapy hours and a quicker recovery focus.

In a rehab to home program, hospital case managers—who are often registered nurses—help patients and their families plan for the return home. Their work starts at the time of admission and continues through discharge. They are responsible for coordinating care and facilitating communication among the patient, family, doctors, hospitals, insurance companies, and other parties.

Case managers can arrange for community and home-based services, if needed. They can coordinate alternate living arrangements and help obtain home medical equipment and supplies, such as walkers, wheelchairs, and shower benches.

For admission into a rehab to home program, patients must have an ongoing skilled need. This includes, but is not limited to, physical therapy, occupational therapy, speech therapy, complex wound care, and IV antibiotic therapy. These customized services can continue in the home, if needed.

To qualify for rehab to home, a patient needs prior authorization as required by his or her insurance plan. For Medicare coverage, a three-day qualifying inpatient hospital stay is required before admission to the program. The day of admission counts, but the day of discharge does not.

With the right support, the transition from hospital to home can pave the way for enhanced recovery and a return to daily life. Benefits of a seamless transition include reduced readmission rates, personal comfort of being at home, and customized care that can be tailored to the specific needs of the patient.

Horizon Health offers a rehab to home program. For more information, call 217-466-4749, 217-466-4340 or visit MyHorizonHealth.org/Rehab2Home.