Rehab at Home (RaH)- How it Works

Following a traditional hospitalization, many frail older patients are admitted to a rehabilitation or skilled nursing facility so they may continue to recover from their illness or surgical procedure, until they build the strength and stability they need to return home. This is called subacute rehabilitation, and while it’s the right option for some patients, others may prefer to return home immediately, with the proper supportand services in place. The Rehab at Home (RaH) program admits patients who are often recommended for the program by in-patient physical therapists, social workers, or discharge planners.

Admitted patients to the RaH program receive physician oversight and RN home visits within 48 hours, as well as physical therapy six days a week. Then a care plan is created for each patient that includes visits from physicians, registered nurses, and social workers. They also receive nursing visits as needed for treatments and IV medications, social work visits, and as needed daily physical, occupational, and/or speech therapy visits. Home care aides may be provided on a very limited basis. These services are delivered for two to three weeks and MACT follows up, as indicated, for up to a total of 30 days. Service intensity varies depending on the needs of the patient and may range from daily clinician visits for high-risk patients to weekly check-in telephone calls for regular-risk patients whose condition(s) are stable or improving.