To help recovering patients get back to normal as smoothly, safely and permanently as possible following rehabilitation, Providence Care Center, skilled nursing facility, has developed a three-phase rehab-to-home transition program called Homeward Bound.

In the first phase of Homeward Bound, patients are evaluated to determine their readiness to resume life in their home community, either independently or with limited outside support.

Next, before discharge, a Providence home assessment counselor inspects the patient's home to determine its livability for that particular patient and to identify conditions, obstacles, hazards or other impediments to a successful return to home life.

Finally, based on the findings of the assessment and recommended modifications that would improve the likelihood of a successful transition, Providence doctors, therapists, care givers and nursing staff collaborate to create an individualized transitional care plan which is reviewed with the patient before discharge and given to him or her for reference and review once he or she returns home.

In addition to suggested modifications to the home, the plan offers recommendations for diagnostic, therapeutic, dietary, pharmaceutical and practical issues that the patient is likely to encounter when living independently again.

For instance, if a home assessment counselor finds that a hip-replacement patient's home has stairs, the plan may prescribe a course of stair-climbing exercises prior to discharge. Or if the patient has limited night vision, the plan may call for something as simple as installing a night light in a dark hallway or replacing a table lamp in the bedroom with a switched ceiling light. Or for patients with limited mobility, removing high-pile or multiple rugs, which tend to make walking difficult for elderly people. More extensive improvements, such as installation of a pedestrian ramp or mechanical lift to manage stairs and improve mobility, may also be recommended.

The core of the Homeward Bound Individualized Transition Plan is the patient-specific educational package which includes tutorials about the patient's condition, and prescribed home therapy, as well as instructions for taking medications, exercise instructions, activity limitations and guidelines for proper nutrition.

In addition to easing the practical difficulties of rehab-to-home transition, Homeward Bound helps alleviate the financial burdens associated with return trips to the hospital. Under new Medicare guidelines, certain conditions such as heart failure, heart attack and pneumonia, require health care services, which are frequently not covered by insurance. Naturally, patients who make a successful rehab-to-home transition will be spared the financial burden of un-insured or under-insured hospital stays.

“Providence Care Center's goal is to provide the most effective services for our clients by developing innovative solutions for rehabilitation and long-term care,” said Providence Care Center director, Raymond DeMarco. "The health care industry is moving away from in-patient hospital care and more toward community and home care models because home care has proven to be just as effective, both clinically and economically, as institutional care: DeMarco continued. “For us, that means providing patients with everything they need to be successful in an independent home environment.”

“Our Homeward Bound program fulfills the requirements of the new health care regulations. At the same time, it motivates hospitals to provide the most effective procedures for their patients, which, in turn, helps produce the best long-term recovery rates for our rehabilitation clients. We want to make our patient’s lives less complicated. Homeward Bound gives them the tools they need to succeed at that. That's what we are about.”