Making a smooth transition to rehab

In an ideal world, most people would prefer to recover from an accident or serious illness in their own homes. But the reality is that inpatient rehabilitation care is necessary for many—especially older adults.

Going from the hospital to a rehab or skilled nursing facility (SNF) can be difficult for the person being admitted, as well as their family and caregivers. There may be concerns about the future and what will happen next.

As a caregiver, you can help ease your loved one’s transition into this new environment and support their recovery. Here are some practical steps you can take.

Establish points of contact

When—or soon after—your loved one is being admitted, ask to talk with the person in charge; that’s usually a unit manager or charge nurse. 

For example, a unit manager will likely handle an admission during the day shift while a charge nurse might handle an admission during an evening shift. Be sure to connect with both to learn who your main contact person is. Likewise, identify yourself (or a family member) as your loved one’s main contact.

Questions to ask

When your loved one is first admitted, a lot will happen at once, and that can be overwhelming. There are several issues you should address with staff soon after admission.

• What is the discharge plan? Don't wait to ask this question. The day of admission is the day to begin planning for discharge.
• What is the rehabilitation goal? The goal is what guides the rehab process, and it’s based on a variety of factors such as your loved one's needs and the nature of the injury or illness that’s being treated.
• Be clear about your expectations, and lay the groundwork for what you want from the care team. Clearly identify the outcomes you and your loved one want. Consider the following:
• Do you want to know about every prescription change, every dosage adjustment?
• If there’s an infection, do you want a family member to be called? Or do you want to hear about it at a regularly scheduled meeting?
• What will happen after rehab goals are reached? Someone at the rehab facility may ask to do a home safety evaluation to ensure that discharge is as successful as possible. For example, if your loved one has a knee replacement and goes to a rehabilitation facility, there are questions about how the transition back home will happen, such as:
• What is the layout of the home your loved one will return to? Are there stairs?
• What care supports will be needed and what will be available?
• What medical equipment does your loved one have or need at home?
• How often will physical and/or occupational therapy be provided?
• How often will a physician evaluate your loved one? In Massachusetts, patients in a skilled nursing facility must be seen by a physician within certain timeframes. Ask the staff at the facility to share the legal requirements.

Share some background information

During an admission to a rehab or SNF, only relevant medical information is provided. In many cases, having some additional details about daily living can be helpful during the transition and beyond. This is something you may be able to provide, or that you could encourage your loved one to share.

This type of information can help the staff at the facility get to know your loved one:

• What is their usual bedtime and wake-up time
• How and when they take their medications
• What makes them anxious
• What will motivate them to encourage the highest level of performance
• If there are any hearing or memory issues and the best ways to work with them successfully

More suggestions for helping your loved one settle in

You may decide to get some of your loved one’s clothes and other personal items. Instead of simply grabbing a few things, think about the right clothing for the setting. Do they need something to keep warm or cool? Is it clothing they’re used to wearing at home? Is that clothing practical for them currently?

If your loved one is having issues with dexterity, for instance, buttons may be difficult or impossible to manage. If they’ve had a hip replacement, pants that can be pulled on (think elastic waistband) are easier than those with buttons and zippers. If they’re doing rehabilitation, they may need sneakers and loose, comfortable clothing. Ask the staff for recommendations—they have the experience to tell you what will work best.

Here are 3 tips to keep in mind when brining any personal items to a rehab or SNF:

• Label all clothes and personal belongings.
• Keep a list of what your loved one has at the facility.
• Don’t bring anything that could be lost or stolen, including cash. Your loved one won’t need money while in the facility.

Originally posted: March 2018
Last updated: July 2025