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How I Helped My Mother Transition From Hospital Care to Rehab

Be prepared to deal with unexpected challenges 

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For the past three years, my sister and I have shared caregiving responsibilities for our mother, who suffers from dementia and advanced Parkinson’s disease. We care for her at home and have watched her mobility and cognition slowly deteriorate. Two months ago, she suffered a health crisis that her doctors couldn’t explain.

As family caregivers, we help our mom with just about everything — cooking, bathing and dressing, helping her manage medication and taking her to appointments. On the day in question, my mother had a normal morning, then suddenly became completely unresponsive. She could not speak or move her legs, and she didn’t seem to hear or understand anything I said.

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Five hours later, her condition hadn’t improved, so her newly assigned home health aide and I got her into the car and to an emergency room. After a week in the hospital, she was transferred to rehab, where she stayed for six weeks. I visited daily, often spending hours at a time. I saw what her days were like, got to know the staff and observed her care.

Expect challenges, communication issues

When transitioning from a hospital to rehab, there are numerous things you can do to make the move easier, including researching rehab facilities in advance, speaking with a hospital discharge planner or social worker, investigating costs and frequently communicating with staff to monitor care and progress. Though my sister is a nurse, and we have been investigating and visiting rehab facilities for more than a year, we did not anticipate many of the challenges we encountered.

Here is some of what we experienced — and what we learned.

Speak with as many people as possible

For the smoothest transition from hospital to rehab, speak with as many staffers and aides as possible as soon as possible. At the hospital, information was not relayed among staff or properly inputted into the computer, so I found myself having the same conversations over and over and correcting mistakes among multiple staff members. My mother’s vegetarian diet was not recorded; her allergies were misrecorded; and though she struggles to bite into large food, her food wasn’t cut up.

The day she was transitioned to rehab, I walked around to find and speak with her new nurse, social worker, dietitian, physical therapist, occupational therapist and activity coordinator, so we could determine daily activities well-suited for my mom. In some cases, I found who I needed by simply speaking with people at the front desk or staff that happened to walk into my mom’s room.

In other cases, I had to find the office of certain people, knock on doors and wander hallways until I eventually ran into them. Some staff (usually higher-ups) suggested we arrange meetings, but others recorded my request right there and passed it on. I learned that the wrong allergy information the hospital noted was passed on to rehab, along with a hospital-prescribed blood pressure medication that neither we nor our mom’s primary doctor found necessary. Having these conversations quickly allowed me to get a head start on smoothing out the transition.

Bring medications to the facility

In my rush to get my mom to the hospital, I neglected to bring her prescriptions and assumed the hospital could fill them. Staffers were able to fill all her prescriptions, but it took more than a day, so she missed several dosages. When she was transferred to rehab, I brought her preportioned medication along for the staff.

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Strategically time visits

As my mother tends to sundown, as is common among people with dementia, I initially planned morning visits, when she is most alert. I noticed that, as in the hospital, she struggled to eat because her food wasn’t cut up. The wheeled meal stand didn’t fit around her wheelchair, so the food was a foot from her body, and she spilled while trying to get it to her mouth. Without a straw, she struggled to drink. She was the only vegetarian in the facility, which was unprepared to accommodate her diet, so she was served cottage cheese at most meals.

I began visiting throughout the day and spoke with a dozen staff members, from part-time aides and full-time nurses to the dietitian and social worker. Care dramatically improved after two weeks. My mother began eating in the dining room (where her wheelchair rolled right up to the table), her food was cut into bite-size pieces, and the center special-ordered bean salads and veggie burgers to mix up her vegetarian proteins.

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The author’s mother, Beverly, and niece, Eva, during a visit in rehab.
Courtesy Cassandra Brooklyn

Bring additional care items

For two years, my mom has relied on a reusable water bottle because it is drop-proof, has a grippy bottom, a handle and a short straw, which is much easier for her to drink from than long straws. I brought it to rehab, along with short, reusable plastic straws, and explained to staff why these products were helpful to my mother (and would make their own jobs easier).

Because staff didn’t have time to wait for my mom to warm up her legs and slowly walk (using a walker and gait belt) to and from the bathroom, dining room and activities, they pushed her everywhere in a wheelchair. I was very concerned about her losing the ability to walk, so I brought her the under-desk pedal bike she uses at home. She needed help getting her feet aligned in the pedals, so my family and I set her up when we visited.

Inquire about services provided

We were pleased to learn that my mom’s rehab facility offered in-house dental and podiatry visits and free transportation to off-site medical appointments. There is no regular schedule, so my mom was put on a waiting list. Due to timing, she wasn’t able to benefit from the dentist, but the podiatrist visited a few weeks after my mom was admitted, so she saw him, and we didn’t have to coordinate a complicated off-site visit.

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Many rehab facilities offer laundry service, including sewing name labels onto clothing so the items don’t get mixed up with other residents’ clothes. (Not all medical plans pay for these services, so confirm pricing in advance.) Unfortunately, we were not informed that clothing cannot be laundered over the weekend, so when an aide gathered my mom’s dirty laundry on a Thursday, it was not washed until Monday. Had we known, we would have washed it at home, so she wouldn’t go without clean clothes.

Her clothing was laundered before name tags were sewn in, so I had to dig through piles of “lost and found” items to identify her things. Once I found them, I requested labeling, and my mom borrowed clothing from the lost and found to wear until her clean clothes returned with labels.

What to bring and what to leave home

Liz Ozminkowski, an ER nurse at one of the largest hospitals in Milwaukee, says every patient’s situation will be a bit different, but there are some general rules about what to bring and what not to bring when admitted to a hospital or rehab. Ozminkowski suggests leaving valuables at home or asking staff to record them and have them locked up. Alternatively, she says that once the patient is admitted, family members can retrieve their wallet, jewelry or other valuables (such as mobile phones) to take home. 


  • Glasses
  • Medications
  • Dentures (if necessary, but keep secure)

Leave home

  • Jewelry
  • Wallet
  • Cellphone
  • Hearing aids (unless critically needed)

Ozminkowski says hearing aids and dentures, which many patients rely on, might be best left at home unless they’re absolutely necessary. Why? They are so expensive and small, they could accidentally get lost in the shuffle. “People often take out their hearing aids and dentures and put them on their lunch trays, which then get tossed out,” she explains. “The same goes with cellphones that people put on their beds, which may get thrown in the wash.”

Because so many patients need dentures to eat, glasses to see and hearing aids to hear, Ozminkowski refers to them as “vital belongings.” She says that hospital staff do their best to keep track of these items — though she acknowledges some could do better — and that “good communication is needed between staff and families to ensure they don’t get lost.”

If your family member requires glasses, hearing aids, dentures or other medical devices that could easily get lost, Ozminkowski recommends making sure nurses and aides are aware of them, and she suggests speaking with your family member about keeping their belongings somewhere safe, such as a side table drawer, instead of a food tray.

Though we had hoped Mom would be able to return home, after six weeks in rehab, we decided it wouldn’t be safe (or practical), so we worked to have her transferred to the memory care unit. Even though it was within the same facility and we were assured all the information would be transferred, we learned that some of it wasn’t, and because there was an entirely new set of staff, I went through the same training process there as I had at the hospital and rehab.

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