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My mother, age 78, had a stroke 3 weeks ago. Yesterday she was transferred to a rehabilitation center where she will stay 2-3 weeks. Her doctors are confident that she will be able to resume a fairly active and independent lifestyle.

I’m prepared to get everything all set for my mother’s return to her home and fortunately, I have friends who have been in similar caregiving situations and they are giving me lots of advice. But I don’t know where or how to start getting things in order. Can you give me a list of what to do?  Julie R., Westwood, NJ.

A lot of what you need to know and prepare for will be included in a personalized discharge plan that the hospital or rehabilitation center prepares for patients and their caregivers when they’re ready to return home. Its purpose is to ensure that the patient is able to safely continue their physical improvement in their own residence, thus reducing the possibility of a hospital readmission. It’s a valuable service that should give you the specific guidance you need to help your mother continue her recovery in the weeks and months ahead.

A discharge plan will include the type of care and services that will be required at home - from help with personal care and meal preparation to home physical therapy; a list of medications your mother takes with specific instructions on how to take them; and it may also include a list of resources such as transport services and home health agencies that service your mother’s area. It is finalized just before your mother’s discharge from the hospital so it will take into account her progress through the last day.

Professional discharge planners quarterback the home rehabilitation process with input from all professionals who provide services to your mother while she is in the hospital. It’s a good idea for you to establish a rapport with this individual early on in your mother’s stay since they can keep you apprised of your mother’s progress and prognosis.

Olga Manrique LCSW, the Director of the Social Work and Care Management Department at Baptist Hospital in Miami, FL explained to me how crucial your involvement will be to your mother’s recovery;“A family’s willingness and ability to support their loved one in these situations makes the difference between good and poor outcomes,” she said. “It begins with meeting with the treatment team, discussing mutual expectations and goals of care, and making sure the family understands what’s involved so that they can support their loved one in complying with the plan.”

Ms. Manrique and the social work and care management team offered some specific examples of how you can begin to implement your mother's post-rehabilitiation care plan at home. 

  • Prepare the home environment and ensure adequate supervision is available
  • Schedule necessary follow-up appointments with the patient’s physicians prior to discharge
  • Determine a plan for transportation to physician appointments
  • Make sure that you or professional caregivers you hire understand your mother’s medication requirements and that her nutritional and medical needs are properly met.

On your mother’s discharge day, allow plenty of time to review the discharge instructions with the nurse to make certain that you understand what needs to be done. If you are going to provide any hands on assistance, ask the staff at the facility to instruct you on the tasks that you will be responsible for. 

Here’s a link to a discharge planning work sheet from medicare. I recommend reviewing it before you meet with the care manager so that you are prepared with questions and your concerns are addressed.  


Your mother is fortunate to have your support and involvement in her recovery.