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When the time comes, the social worker in the hospital will be working with you regarding next steps in your loved one’s care.  The route you take will be mainly driven by the medical status of your loved one.  Below are some of the options: 

• Sub acute facility

• Nursing home

• Home

The timing as to when to leave the hospital is more art than science and may make you feel uncomfortable.  Your first instinct may be to resist leaving since the change to a new facility is unsettling by itself.  Second, it is only natural to have developed a comfort level with the hospital and the staff.  Third, you have probably never been in this situation before, so it is going to be very difficult for you to gauge whether your loved one is ready to be released or not. 

 On the flip side, as a doctor told our family, one of the worst places to be when you are ill is in the hospital as many of the toughest germs live there.  Plus the change can be good, the new facility may provide some new ideas and new enthusiasm and a welcome spark. 

Unfortunately, there are other outside factors involved in the decision process that makes it even harder you to feel comfortable.  Hospital patient levels fluctuate from day to day and what we have seen is that as patient levels rise, pressure may be put on the staff to clear space on the floor.  While I am sure they would never endanger anyone, I think sometimes people do get rushed.  Another factor is your insurance company.  If your insurance company is putting pressure on the hospital to get you released you may again be rushed.

 Hopefully, you have developed a good relationship with your doctor so that you can feel comfortable with their recommendation.  If you do not think you are ready to leave and your doctor agrees, do not hesitate to fight the fight to advocate for your patient’s best interest.

 If more structured care is necessary you may be directed to a sub-acute facility or a nursing home. 

A sub-acute facility is better able to handle the more involved patients, especially those still on a ventilator.  They typically have more highly trained staff than a nursing home.  In our case, we found a great facility that rented floor space in a local hospital.  This set-up was ideal as one of our primary concerns was the facilities’ capabilities in an emergency situation.  The sub-acute facility had an arrangement where the hospital’s trauma team would respond to a code situation on the sub-acute floor the same as they would on their own hospital floors.  The other facility we were considering was a stand-alone facility and their emergency response was that their staff would treat the patient while they called 911 and waited for an ambulance.

 Below are some suggestions in making your choice.

 This has got to be our number one suggestion.  Talk to everyone you can, get as many opinions as you can, but you have got to actually visit the facility and make sure you are comfortable there. 

One of the most important criteria should be is there enough staff.  Ask what the patient to staff ratios are for all of the disciplines your patient requires, e.g. nursing, respiratory therapists, nurses aides, doctors, therapists.  Benchmark the answers you get to the ratios from the other facilities you are considering.  Compare the ratios to the hospital but keep in mind that they will probably be higher as these facilities are less acute than the hospital. 

 Remember, if your patient is on a ventilator, the number of respiratory therapists is critical.  You want to make sure the vent alarms are answered promptly and the maintenance care is done timely.  Finally, you also may consider visiting the facility off-hours to get a feel for the staffing levels during all hours of the day.

 Check out the rooms where your loved one will be.  Are the rooms clean?  Are they large enough?  Do you want private or semi-private?  Do you feel comfortable that there are adequate safety measures and equipment in place? 

Also check out the facilities they have for therapy.  Can they provide the level of therapy you desire in all three disciplines, Speech, OT, PT?

 Are the visiting hours lenient enough for you?  If it is our family, can someone stay in the room 24 hours a day, every day.  Do they have an arrangement with a local hotel for lodging?  What about a cafeteria or restaurants nearby?

 Finally, we suggest you do not transfer in to a new facility on the weekend.  Typically, the support staff and may be even the floor staff are reduced on the weekend and it is not the way to start your stay at the new facility.  We have heard more than once that this has caused problems.  The pushback you will get will come from the hospital you are currently in who are trying to clear space on the floor.  Try to partner with your doctor to help convince the hospital and the insurance company that you need to stay until Monday.    

 The sub-acute facility is considered to be a step-down from the level of care provided in a hospital.  This is a good thing as it means your patient is more stable and does not require the higher hospital level of care.  At the same time you need to continue to be vigilant in watching for medical errors and stopping them before they happen.

 You may have some mixed feelings as you move to this new facility.  There may be some trepidation as you leave a situation in the hospital that you had developed a certain level of comfort.  You may feel some sense of despair that others who you were in the ICU and on the neuro floor with have progressed to a rehab unit or even home while your loved one is not progressing as fast.  At the same time, you may get a new burst of energy from the new staff and some new approaches.

 If your loved one is on a ventilator you need to work with the doctors to understand their plan for weaning them off the ventilator.  As I understand it, the longer a person is on a ventilator the more dependent they become.  For our family, weaning off of the ventilator was our number one goal.  Our doctor in the sub-acute facility put together an aggressive plan and weaned our daughter after other doctors in the hospital had said she would never be able to come off of it. 

 They slowly reduced the work the ventilator was doing but took care not to tire her out.  Our daughter did have one quirk in that after a certain level the lower they continued to take the ventilator settings her oxygen levels also went down. Not a good thing.  What did work was going down to a certain point and then stopping it completely.  (Actually the setting they used is called CPAP, which allows the person to breathe all on their own but provides emergency protection in case they should stop.)  They then let her build up her endurance on CPAP until she could breathe on her own longer and longer without getting too fatigued.  Getting rid of the ventilator was a huge victory. 

Most sub-acute units will have therapists available.  Make sure you speak with the doctors and therapists and let them know you want to stay aggressive.  Our first day in the sub-acute facility the physical therapist came by to do his initial assessment.  He said he thought we should get my daughter up sitting on the edge of the bed.  My response was fine, that is a good goal to shoot for.  After all, my daughter was on a ventilator and barely had any movement at all.  His answer was no, I mean tomorrow.  And they did. 

 Mentally you have to steel yourself that you are in for the long haul with this injury.  The fact that you are in a sub-acute facility probably means that your patient was more severely injured.  It means the road is going to be longer and harder.  Well, that is fine.  You and your loved one have fought to get to this point and you can just keep fighting and keep making steps toward a recovery.  Remember to keep everything positive and keep marching to your goals.

 You probably had built some relationships and friendships with the staff in the hospital.  Now, you need to do the same in this unit.  Again, there is a lot to learn and this staff will also be glad to help you.  Your next step may be home so make sure you ask questions and let the staff supervise as you learn some of the tasks you may need to do at home. 

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