Introduction to Discharge Planning
The Department of Care Management and Social Work welcomes you to Rusk Rehabilitation. As you and your family transition here with us, you will be taking in a lot of new information. This introduction helps explain the discharge planning process. It also has extra resources you may find helpful. Social Work is here to support you and your family. We will make sure you understand the rehabilitation (rehab) program and recommended discharge plan. It is our goal to meet your needs. We look forward to working with you and your family. We also extend our best wishes for your rehab and recovery.
Glossary
Disclosure Statement
A form created by your rehab team and provided by your social worker. It is an individualized plan that addresses your rehab services, goals, estimated length of stay, insurance carrier and projected discharge plan. Social Work will explain and answer any questions about this form.
My Health Information Profile
A summary of important facts about your personal health, medical history and other related information. This is very helpful to have when you visit doctors or have an emergency and need to share vital information. Your social worker will show you where this form is located in your Rehab Notebook.
Projected Discharge Date
Discharge planning starts the week you are admitted. It begins at the initial team meeting. A projected discharge date and plan are determined. Your insurance benefits will also be considered when creating a projected discharge date and plan.
Length of Stay
Your length of stay is reviewed by the rehab team every week. Some of the things involved in deciding how long you will stay are whether you will:
- Need daily medical intervention.
- Show potential to make measurable gains in therapy.
- Be able to participate in 3 hours of therapy daily
If there are any concerns about meeting the 3 points noted above, we will let you know.
Discharge Planning Process
Your doctor will work with the rest of your health care team and your family to recommend a plan. This plan will include your medical and nursing care needs as well as your ongoing rehab goals.
Discharge to Home
Discharge to your home depends on how well you are functioning. We also need to make sure you are able to have the services and supervision you will need at home. Therefore your discharge plan may allow you to go home but with home care services or outpatient services.
Home with Home Care Services
Social Work will make a referral for home care services. The referral includes therapy and nursing services for you at home. Services provided in a home setting are based on two things: your medical needs and whether your insurance will cover them.
Depending on your medical needs, services offered through a home care agency include:
- Physical Therapy
- Occupational Therapy
- Speech Language Pathology
- Registered Nurse, Social Work
- Home Health Aide.
Home with Outpatient Services
If your condition has improved to the point where you don’t need services in your home, then you can do outpatient therapy. If you and your family agree, we can refer you to outpatient therapy at NYU Langone Medical Center. We can also give you a list of other facilities and agencies that do outpatient therapy based on your preferences, location, needs and insurance provider. Outpatient therapies include:
- Physical Therapy
- Occupational Therapy
- Speech Language Pathology
- Neuropsychology
- Vocational Rehab.
Family Training
If you need extra help from family after you are discharged, we can train them. During therapy sessions, a therapist will go over precautions and ways to safely help the patient.
Extended Supervision
You will not go home from rehab without the supervision you need. If you need more extended supervision than your insurance will cover, your family may need to help or you may need to hire a private aide or companion. Social Work will help you by giving you information about agencies and going over it with you before your discharge
Durable Medical Equipment
Your Physical and Occupational Therapists (PT and OT) will order any equipment that you will need when you go home. This is done before you are discharged. Later on a Home or Outpatient Therapist can decide if any other equipment is needed.
Common Durable Medical Equipment items:
| Physical |
Occupational |
Rolling walker
Rollator
Wheelchair
Forearm crutches
Cane |
Commode
Shower chair
Bath seat
Raised toilet seat
Reacher
Long shoe horn |
Discharge to a Residential Care Facility (RCF)
An RCF also known as a “subacute,” is a facility that offers continued rehab in an inpatient setting. These facilities tend to be in Skilled Nursing Facilities (SNF) or Nursing Homes but they are maintained as separate units for short term rehab.
Patients usually go to subacute facilities when they are medically stable, ready for the next level of care, and will benefit from continued inpatient rehab. Admission is based on medical acceptance to the facility, insurance clearance and bed availability. Discharge to a subacute may start before the initial discharge date if acute rehab level of care is no longer needed.
If discharge to a subacute facility is recommended, your Social Worker will give you and your family a list of subacute facilities. You and your family should decide on at least five choices you are comfortable with. If your discharge date changes, you can all start researching facilities at time of projected discharge plan to subacute. Your Social Worker will help with your discharge to subacute and send any needed paperwork to your preferred facilities for review.
Transportation and Discharge Time
Your Social Worker can arrange for transportation from Rusk. If you are being discharged home, depending on how well you are functioning, your family may take you in a private car or arrange for a car service. You and/or your family will be responsible for providing or paying the transportation cost. Transportation by ambulance or ambulette is not often covered by insurance. Discharge is usually at 11:00am but this may change.
Helpful Resources
Questions and Concerns
Your Social Worker is open to answering any questions you and your family may have. Please feel free to contact us.
Covering Social Worker (SW): ___________________________________________
Contact Information for SW: ___________________________________________
© NYU Langone Health. All rights reserved. Reviewed for health literacy. This information is not intended as a substitute for professional medical care. Always follow your health care provider's instructions.
Introduction to Discharge Planning
The Department of Care Management and Social Work welcomes you to Rusk Rehabilitation. As you and your family transition here with us, you will be taking in a lot of new information. This introduction helps explain the discharge planning process. It also has extra resources you may find helpful. Social Work is here to support you and your family. We will make sure you understand the rehabilitation (rehab) program and recommended discharge plan. It is our goal to meet your needs. We look forward to working with you and your family. We also extend our best wishes for your rehab and recovery.
Glossary
Disclosure Statement
A form created by your rehab team and provided by your social worker. It is an individualized plan that addresses your rehab services, goals, estimated length of stay, insurance carrier and projected discharge plan. Social Work will explain and answer any questions about this form.
My Health Information Profile
A summary of important facts about your personal health, medical history and other related information. This is very helpful to have when you visit doctors or have an emergency and need to share vital information. Your social worker will show you where this form is located in your Rehab Notebook.
Projected Discharge Date
Discharge planning starts the week you are admitted. It begins at the initial team meeting. A projected discharge date and plan are determined. Your insurance benefits will also be considered when creating a projected discharge date and plan.
Length of Stay
Your length of stay is reviewed by the rehab team every week. Some of the things involved in deciding how long you will stay are whether you will:
- Need daily medical intervention.
- Show potential to make measurable gains in therapy.
- Be able to participate in 3 hours of therapy daily
If there are any concerns about meeting the 3 points noted above, we will let you know.
Discharge Planning Process
Your doctor will work with the rest of your health care team and your family to recommend a plan. This plan will include your medical and nursing care needs as well as your ongoing rehab goals.
Discharge to Home
Discharge to your home depends on how well you are functioning. We also need to make sure you are able to have the services and supervision you will need at home. Therefore your discharge plan may allow you to go home but with home care services or outpatient services.
Home with Home Care Services
Social Work will make a referral for home care services. The referral includes therapy and nursing services for you at home. Services provided in a home setting are based on two things: your medical needs and whether your insurance will cover them.
Depending on your medical needs, services offered through a home care agency include:
- Physical Therapy
- Occupational Therapy
- Speech Language Pathology
- Registered Nurse, Social Work
- Home Health Aide.
Home with Outpatient Services
If your condition has improved to the point where you don’t need services in your home, then you can do outpatient therapy. If you and your family agree, we can refer you to outpatient therapy at NYU Langone Medical Center. We can also give you a list of other facilities and agencies that do outpatient therapy based on your preferences, location, needs and insurance provider. Outpatient therapies include:
- Physical Therapy
- Occupational Therapy
- Speech Language Pathology
- Neuropsychology
- Vocational Rehab.
Family Training
If you need extra help from family after you are discharged, we can train them. During therapy sessions, a therapist will go over precautions and ways to safely help the patient.
Extended Supervision
You will not go home from rehab without the supervision you need. If you need more extended supervision than your insurance will cover, your family may need to help or you may need to hire a private aide or companion. Social Work will help you by giving you information about agencies and going over it with you before your discharge
Durable Medical Equipment
Your Physical and Occupational Therapists (PT and OT) will order any equipment that you will need when you go home. This is done before you are discharged. Later on a Home or Outpatient Therapist can decide if any other equipment is needed.
Common Durable Medical Equipment items:
| Physical |
Occupational |
Rolling walker
Rollator
Wheelchair
Forearm crutches
Cane |
Commode
Shower chair
Bath seat
Raised toilet seat
Reacher
Long shoe horn |
Discharge to a Residential Care Facility (RCF)
An RCF also known as a “subacute,” is a facility that offers continued rehab in an inpatient setting. These facilities tend to be in Skilled Nursing Facilities (SNF) or Nursing Homes but they are maintained as separate units for short term rehab.
Patients usually go to subacute facilities when they are medically stable, ready for the next level of care, and will benefit from continued inpatient rehab. Admission is based on medical acceptance to the facility, insurance clearance and bed availability. Discharge to a subacute may start before the initial discharge date if acute rehab level of care is no longer needed.
If discharge to a subacute facility is recommended, your Social Worker will give you and your family a list of subacute facilities. You and your family should decide on at least five choices you are comfortable with. If your discharge date changes, you can all start researching facilities at time of projected discharge plan to subacute. Your Social Worker will help with your discharge to subacute and send any needed paperwork to your preferred facilities for review.
Transportation and Discharge Time
Your Social Worker can arrange for transportation from Rusk. If you are being discharged home, depending on how well you are functioning, your family may take you in a private car or arrange for a car service. You and/or your family will be responsible for providing or paying the transportation cost. Transportation by ambulance or ambulette is not often covered by insurance. Discharge is usually at 11:00am but this may change.
Helpful Resources
Questions and Concerns
Your Social Worker is open to answering any questions you and your family may have. Please feel free to contact us.
Covering Social Worker (SW): ___________________________________________
Contact Information for SW: ___________________________________________
© NYU Langone Health. All rights reserved. Reviewed for health literacy. This information is not intended as a substitute for professional medical care. Always follow your health care provider's instructions.