Smooth Moves: The Aging Services Seniors Need for An Easy Transition Back Home

When I was the Director of Social Services at a SAR (Sub-Acute Rehabilitation) center, one of my most important jobs was to oversee patients’ discharge planning. Most of our short-term clients were older and had endured traumatic experiences such as car accidents, falls, hip replacements, and other debilitating events. Not only did this affect their ability to function in the present, but it also made preparing for their continued functioning at home all the more important.
Read on to see what type of aging services your loved one may need when returning home from a SAR, hospital, or another facility.

DME (Durable Medical Equipment)

DME (Durable Medical Equipment) for your loved one can be anything from an oxygen tank to a hospital bed. It’s important to have the necessary equipment in place or ready for use before your loved one begins their transition. The most common pieces of equipment are ambulatory devices such as wheelchairs and walkers. They can be ordered from a facility and even delivered to the home before your loved one is discharged.

Continued therapy

Continued home p.t. (physical therapy) and/or o.t. (occupational therapy) is often a key component of a smooth transition from a care facility to home. Therapists are available to work with your loved one several days a week, often for a few weeks, to reinforce the skills learned in rehab that they’ll continue to need.


Transportation is something that family members or home health aides often take care of. Or, for more complicated cases, an ambulance service can be arranged (for example when the patient is bedbound, or in a wheelchair and cannot easily transfer in and out). However, please note that while your coordinator may be happy to schedule certain types of transport, they may not be covered by your loved one’s insurance company. Patients often opt for assistance with wheelchair transport by ambulance, only to find out that Medicare does not pay for this service!

Visiting Nurse

Wound care, infusion therapy, and medication monitoring are all things that a visiting nurse can provide for your loved one at home. They typically come for these short-term services two or three times a week, but can visit as often as a physician recommends.

Home Health Aide

One of the most important parts of a stress-free transition is a home health aide. These professionals provide many of the same services that the aides in the hospital or rehab did. For instance, they can bathe, dress, and feed your loved one in addition to performing chores around the house that older adults find difficult.

Other Services

Other aging services your loved one may need at home include consults for nutritionists, mental health professionals, hospice, and more. Most services involve the patient’s physician writing a prescription for them, the same way they do for medications. This includes everything from medical equipment to continuing therapies; from visiting nurses to home health aides. The person coordinating the transition can offer additional tips and advice applicable to your loved one’s unique situation. They should also be available to help you do as much as possible in advance.

When Aging Services Are Lacking, The Consequences Can Be Severe

When aging services are lacking, the consequences can be severe. A poor transition can sometimes lead to a permanent loss of your loved one’s physical abilities and functioning. Lack of physical therapy can cause a decline in muscle tone, range of motion, and respiratory capacity. Lack of a home health aide also puts your loved one at risk for falls. That’s why we cannot stress enough the importance of having the right aging services in place for a patient’s return home.

Work With Someone You Trust for Your Loved One’s Big Move

If your loved one has a move home scheduled, you may be coordinating things with a social worker, nurse manager, or another type of discharge planner. But regardless of the caseworker assigned to you, make sure the aging services at home will be arranged with a provider that you trust. Scheduling a meeting or call with them prior to your loved one’s transition can be a great way to get acquainted. Remember – everyone involved with the move should want the best thing for your loved one: smooth sailing all the way!
If you are unsure of how to best help an aging loved one, the trained and compassionate staff at the Institute on Aging is here to help you make that decision and gain the best in at-home care for older adults. Contact us to find out more.

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