Leaving a skilled nursing facility is good news. It means your loved one has gotten stronger. But going home after a skilled nursing facility in Tampa, whether it was a short rehab stay or a longer one, is also a big change. In the facility, nurses gave the medicines, therapy happened every day and help came at the press of a button. At home, your family takes on much more. Home health care helps close that gap with nurses and therapists who visit your loved one at home while they settle in. This guide explains how to plan the move, set up the home, sort out medicines and keep therapy going.
If your loved one is coming straight home from a hospital instead, see our guide to coming home after a hospital stay.
Going home after a skilled nursing facility: start planning early
The best transitions start well before the last day in the facility. Ask for a care meeting with the facility’s social worker or discharge planner, the therapy team and the nurse. Bring a family member who will help at home, and bring your questions:
- What is the planned discharge date, and what has to happen first?
- What can my loved one do alone, and what do they still need help with?
- Which medicines are new, changed or stopped since before the hospital stay?
- Is there a wound, catheter, special diet or other care to continue at home?
- What equipment is needed, such as a walker, wheelchair, shower chair or hospital bed? Who orders it, and when will it arrive?
- Which doctor will follow my loved one after discharge, and who will sign the home health orders?
- When are the follow-up appointments?
Choose your home health agency early
If the doctor orders home health care, you can choose the agency. With Original Medicare, you can pick any Medicare-certified agency that serves your address and accepts your loved one. Medicare Advantage plans usually require an agency in the plan’s network. Tell the discharge planner which agency you want, or have a family member call the agency so the referral is sent before discharge day.
Gather the paperwork
Ask the facility to send these to the home health agency and to give you copies:
- The current medication list, with the time of the last dose of each medicine
- Therapy notes, including how far your loved one can walk and how they transfer
- Wound care, catheter or diet orders
- The discharge summary and follow-up appointments
Keep everything in one folder by the door. It helps the first home visit and any trip to the emergency room.
Set up the home before arrival
A home that worked fine before a hospital stay may not work now. Walk through it with fresh eyes, or ask the facility therapist what to look for.
- Choose the main room. If stairs are hard, set up a bedroom on the main floor for now.
- Clear the path. Make a wide, clear path from bed to bathroom to chair, with no rugs, cords or clutter.
- Light the way. Add night lights in the bedroom, hall and bathroom.
- Ready the bathroom. Plan for a shower chair or tub bench, a raised toilet seat and grab bars where they can be installed. Towel bars will not hold a person’s weight.
- Check the chair and bed height. A firm chair with arms is easier to rise from. Feet should rest flat on the floor when sitting on the edge of the bed.
- Get equipment delivered first. Ask the supplier to deliver the walker, bed or commode before your loved one arrives.
- Plan for power outages. If your loved one uses oxygen or other powered equipment, talk with the supplier about a backup plan.
- Stock the kitchen. Have easy meals that fit any diet orders, and water within reach.
Our guide to fall prevention at home has a full room-by-room checklist.
Medication reconciliation: sort it out on day one
In the facility, nurses handed out every pill. At home, someone has to know exactly what to take and when. Medication reconciliation means comparing the facility’s discharge list with every medicine in the house. This is where many mistakes start, because the home cabinet often still holds bottles from before the hospital stay.
Common problems include:
- An old dose still in the cabinet after the doctor changed it
- A medicine the facility stopped that is still taken out of habit
- The same drug under a brand name and a generic name, taken twice
- A new prescription that was never filled
- Confusion about timing, especially for medicines given at set hours in the facility
- Over-the-counter pills or supplements that do not mix well with new prescriptions
Before your loved one comes home, take the discharge list to your pharmacy and fill any new prescriptions. Set aside, but do not throw away, old bottles until the nurse has reviewed them.
At the first visit, the home health nurse goes through every bottle, including inhalers, eye drops, creams and vitamins. The nurse compares them with the discharge list, reports any mismatch to the doctor, and helps you set up a system you can follow, such as a pill organizer and a written schedule. Learn more about medication management at home. Never stop or change a medicine on your own; follow your doctor’s instructions.
Keep therapy going at home
Much of the progress in a skilled nursing facility comes from daily therapy. Stopping cold at discharge can undo those gains. Home health therapy picks up where the facility left off, in the real setting your loved one has to manage.
- Physical therapy works on strength, balance, walking and stairs, including the front steps and the path from the car.
- Occupational therapy works on bathing, dressing, toileting and kitchen tasks in your loved one’s own bathroom and kitchen, and suggests equipment and safer ways to do each one.
- Speech-language therapy continues work on swallowing, speech or memory when those were part of the facility plan.
Home therapy visits are less frequent than in a facility, so the home exercise program matters. Ask the therapist to write it down, and ask family members to watch at least one session so they learn safe ways to help with transfers.
What skilled nursing at home looks like
A home health nurse is the hub of care after a facility stay. Depending on the doctor’s orders, skilled nursing visits may include:
- Checking vital signs, breathing, weight, swelling and blood sugar trends
- Wound care and dressing changes
- Catheter care
- Teaching about heart failure, COPD, diabetes or other conditions
- Watching for infection, dehydration and side effects
- Updating the doctor when something changes
The nurse also teaches your loved one and family the warning signs to watch for between visits.
Warning signs in the first weeks home
Call the doctor, or the agency during office hours, if you notice:
- A fever, chills or a cough that is getting worse
- New confusion, extreme sleepiness or unusual weakness
- Not eating or drinking, or trouble swallowing
- Redness, swelling, drainage or odor at a wound
- Swelling in the legs, sudden weight gain or more shortness of breath
- A fall or a near-fall
- Pain the medicines are not controlling
Call 911 right away for chest pain, severe trouble breathing, signs of stroke such as face drooping, arm weakness or trouble speaking, fainting or heavy bleeding.
Moving home after a long facility stay
Some families consider bringing a loved one home after months in a long-term care facility. It can work, but plan honestly. Home health visits are part-time. Someone still needs to cover the rest of the day and night, whether that is family, privately arranged help or both. Before the move, line up equipment, make sure the home is accessible and talk through a backup plan if a caregiver gets sick. Our medical social worker can help you find community resources and plan what comes next.
Who qualifies for home health care after a skilled nursing facility?
A facility stay does not automatically mean home health care is covered. Medicare covers home health care when all of these are true:
- A doctor or allowed practitioner orders it. This can be a doctor, nurse practitioner, clinical nurse specialist or physician assistant. They certify that your loved one needs care at home and review the plan of care.
- Skilled care is needed on a part-time or intermittent basis. That means skilled nursing, physical therapy or speech-language therapy, or continued occupational therapy.
- Your loved one is homebound. Leaving home takes considerable and taxing effort. Short, infrequent outings for medical care, religious services or adult day care are OK.
- There was a face-to-face visit about the main reason for home health care, within 90 days before or 30 days after care starts. A visit with the doctor or practitioner who cared for your loved one in the facility can count.
- The agency is Medicare-certified.
People leaving a facility often qualify because they still need therapy, wound care, medicine teaching or close watching of a chronic condition. Medicare does not cover 24-hour care at home, meal delivery, or help with bathing and housework when that is the only care needed. Other plans have their own rules and may need approval first. We accept Traditional Medicare, plus long-term care plans and private pay. Medicare Advantage coverage and our participation depend on your specific plan, so we verify both before care starts. Call (813) 931-0015 to verify your coverage, or see our insurance page.
How Making Memories Home Health can help
Making Memories Home Health is a Medicare-certified, Joint Commission-accredited home health agency based in Tampa. We coordinate with discharge planners at skilled nursing facilities, rehab centers and hospitals so care can be planned before your loved one comes home. Our nurses, therapists, medical social worker and home health aides work from one plan of care, and our team speaks English and Spanish. Current patients can reach our on-call nurse 24/7 by phone.
We serve Hillsborough, Polk and Manatee counties. If your loved one is getting ready to leave a facility, call us at (813) 931-0015 before discharge day. We verify your benefits and explain any costs before care starts. Doctors and discharge planners can send a referral online.
Frequently asked questions
Can home health care start the day my loved one leaves the facility?
The first visit is scheduled once the agency has the referral and the doctor's order. The best way to avoid a gap is to choose an agency several days before discharge and ask the facility to send the referral early. Ask the agency when they plan to make the first visit.
Will my loved one get as much therapy at home as in the facility?
Usually not. Facility therapy is often daily, while home health therapy is a few visits a week, set by the doctor's orders and the plan of care. Home visits focus on the exact tasks your loved one needs at home, and the therapist leaves a home exercise program to do between visits.
Who will be the doctor after a skilled nursing facility stay?
In many cases the facility doctor stops following your loved one at discharge, and the primary care doctor or a specialist takes over. Ask the facility who will sign the home health orders and make the follow-up appointment before you leave.
Does home health care provide someone to stay with my loved one?
No. Home health care is made up of scheduled, part-time visits from nurses, therapists and aides. If your loved one cannot be alone, family or other help needs to cover the rest of the day and night, and our medical social worker can help you look at options.