Cheryl Martin (Host): This question could cause some people anxiety, what if your family members are not strong enough to be safe at home when they are getting discharged from the hospital? Well, Woodlawn Hospital has a solution with its Rehab to Home Service. And here to tell us how it works and how you can assess if it's a good fit for your loved one is Teresa Perkins, an orthopedic nurse practitioner at Woodlawn Hospital.

This is Woodlawn Health Doc Talk, a podcast from Woodlawn Hospital. I'm Cheryl Martin. Teresa, so glad you're on to talk about the program, Rehab to Home.

Teresa Perkins: Thank you. I'm glad to be here.

Host: First, explain what it is and how its services differ from those provided in a traditional hospital or nursing home setting.

Teresa Perkins: Yeah. Rehab to Home is a program that is often known by the word swing bed and is used synonymously. Basically, what it does is it is continued rehab after a couple different things. Either you're in the hospital and have just had a surgery or there's some other medical issues that we'll cover later that can be included in this as well. And basically, it's just a continuation of care and the status of care changes where you move from a hospital inpatient to a rehab patient. And so, your status changes because your care is different.

Host: So, what are the potential benefits, Teresa, of choosing rehab to home care, let's say, over a conventional rehabilitation facility for a loved one's recovery process?

Teresa Perkins: The big benefit is that if family is near and you are in our hospital and you live in this community, then your family and your friends can visit you here. You move from an inpatient, instead of being discharged from the hospital and going to another facility, whether it be rehab or a skilled nursing facility, you would instead stay in the hospital and, in many cases, stay in the exact same room you're already in, except the status changes from an inpatient to a rehab patient, where then you would continue to have care 24/7 until you are ready to go home. And the goal is that with some extended time in that program, then you would be able to go home straight from a rehab to home or swing bed program.

Host: So, you're saying your loved one would stay at the hospital, but would just be enrolled in the rehab to home care?

Teresa Perkins: That is correct.

Host: Okay. So, Teresa, give us some specific examples of medical conditions or recovery scenarios where rehab to home or swing bed care would be particularly advantageous.

Teresa Perkins: For instance, in Orthopedics, which is my area of expertise, we have patients that have an orthopedic surgery that can't go home that same day, but may need an inpatient stay. They will stay, depending upon their insurance, a certain amount of time as an inpatient. And then, if they're still not ready to go home to, let's say, be by themselves, if they live alone originally or routinely and don't need help, then their goal is to get back home without needing someone else there, they may need some extra rehab.

There are also some medical issues that sometimes will keep people in the hospital and could consider rehab to home or swing program, including general surgery patients, patients with respiratory illnesses that might need treatments, and IV infusions every eight or every 12 hours instead of going home and coming into the hospital once a day. Those who have IV orders for every 8 or 12 is just unreasonable for them to drive in here two or three times a day for IV infusions, those would be people that would qualify for this kind of a program. Also, people who have had heart surgery, we do not do that surgery here, but where they've had heart surgery elsewhere or any other type of surgery or care and want to come back to their community for continued rehab can also be admitted to our swing bed program.

Host: So, what are some common misconceptions about this program that families and patients should be aware of?

Teresa Perkins: Probably one of the biggest and most important, of course, for this to work well is whether or not the insurance that the patient has actually covers this and, if they do, how does it cover it? Traditional Medicare, it does require three days of an inpatient status. Even though they don't need authorization, they still need a three-day minimum inpatient, then can transfer to the Rehab to Home Program. And usually, the first 20 days is covered 100% under traditional Medicare. Then, generally, it would might go to like an 80/20 percent where 80% of it is covered by insurance. The patient would cover 20% and then there's continuing evaluation and re-evaluations of what kind of care the patient still needs or does not need before they're discharged.

Medicare replacement programs are the ones that would need authorization and they generally would cover maybe three to five days of rehab to home swing bed program. Coverage thereafter is depending upon individual insurance policies, the patient's progression of care, their ability to participate in the physical therapy, and are safe to go home.

Host: Now, what are some practical steps that families can take to support their loved ones during their stay in the Rehab to Home program?

Teresa Perkins: When it is safe for family and friends to visit, and most people, unless they're in an isolation situation or something like that, then visiting the patient there, encouraging them to progress, and affirm their support for the patient when they do come home, but the Rehab to Home is really important to have the patients' compliance with the orders of physical therapy or occupational therapy and their IV treatments and those kinds of things. And family and friends can be really encouraging towards that.

Host: Now, Teresa, what is a process for transferring a patient from acute hospital care to a rehab to home facility? And what should families expect during this transition?

Teresa Perkins: The transition for the patient and what they can expect is generally as long as the number of beds in the census will allow, again, like I had mentioned before, they can stay in the same room. Nothing really changes on that end. They will continue to have physical therapy. What's also great about this situation where the Rehab to Home swing bed is part of the hospital floor right where you're already being taken care of as an inpatient, that you just continue all the continuing of care right there that you've been getting, and it just continues on until you're ready to go home.

The goal is, again, that you go home. The difference too, if you go to a rehab facility or skilled nursing care, that sometimes there is not a provider on campus and being in the hospital in a swing bed program, there is a provider there 24/7 in case there is a change in the patient's status. If there is something that would require skilled nursing again, then you can transfer back from rehab to home status back to an inpatient. Thankfully, that doesn't happen very often. But when it does, it's, again, an easy change. They stay in the same room, they're just back getting more skilled status. They change to a skilled status again and can get the care that they need. We have nurses that are there 24/7. They also have access to labs and radiology and all of the treatments that you might need right there available in the same building.

Host: That's some good information to know. Now, if a patient is interested in signing up for Rehab to Home, is this a program that the hospital would mention is a viable alternative? Or should the patient go in knowing about this and says to them, "This is what I want," or do they call you? How does that part work?

Teresa Perkins: Usually, when a patient is admitted to the hospital, this information is shared with them with the case manager, Michelle Hensley, in our hospital program, and she does case management and utilization review in the swing bed or Return to Home Program. And she's the coordinator of that, so that's something where from the day they are admitted, this education starts because that way, if the patient does not seem to progress as well as they would like or maybe the doctor or caregivers would like, then the Rehab to Home has already been talked about and they know that this is a possibility and certainly getting the word out that it is available. I do that with my pre-op teaching here in my clinic and let patients know that are having surgery that, if for whatever reason they're not advancing as quickly as they should or they need extra rehab, that this program is available.

Host: How does Rehab to Home address the challenges of providing care in rural areas with limited healthcare resources?

Teresa Perkins: Well, the swing bed rehab to home addresses the need for care in these rural areas by providing services that would normally require a patient leaving a rural hospital or rural area after surgery to rehab elsewhere.

What's great is that we can keep them here in a place that is familiar where they are able to see their family and their friends and not having family and friends travel or they have to travel or be discharged and transported from our hospital elsewhere.

 So, it's local and it's full care continuum from the time that they are admitted, and have a surgery or need some kind of inpatient care that they can transfer out of that status into rehab and get them home, and all of that is done right here in their local community.

Host: Anything else, Teresa, you'd like to add just about the Rehab to Home program?

Teresa Perkins: I'm just really grateful that our small town hospital, rural hospital, offers such a wonderful service, with great rehab and follow through, and that we can provide this to our community, and that they can stay right here where they're comfortable.

Host: Teresa Perkins, thanks so much for coming on to discuss Woodlawn's Rehab to Home Program. A great service. Thank you.

Teresa Perkins: Thank you so much. I appreciate it, Cheryl.

Host: For more information to help you or a loved one, just call our Rehab to Home coordinator at 574-224-1015. That's 574-224-1015. Now, if you found this podcast helpful, please share it on your social media and thanks for listening to Woodlawn Health Doc talk, a podcast from Woodlawn Hospital.