Complexities of Senior Healthcare: Next Steps After-Hospitalization - Mary Ann Morse Home Care

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Complexities of Senior Healthcare: Next Steps After-Hospitalization

Leaving the hospital following an illness or surgery marks a significant moment. Yet it can also be a bit confusing, leaving you to wonder, “What’s next?” Here are some options to consider to help you transition from hospital to post-hospital care and facilitate a smoother path forward:

Inpatient Rehabilitation Facilities (IRFs)

Inpatient Rehabilitation Facilities (IRFs) provide intensive rehabilitation services for patients requiring daily therapy and medical supervision. These facilities offer comprehensive rehabilitation programs tailored to assist patients in regaining functionality and independence following an illness, surgery, or injury. The duration of stay in IRFs depends on the patient’s progress and needs, typically covered by Medicare/insurance.


Visiting Nurse Agency/Home Health Care

Home health care delivers essential medical services within the comfort of your own home. Skilled healthcare professionals, including nurses, therapists, and aides, visit patients to provide necessary care such as wound care, medication management, and rehabilitation exercises. Home health care is an excellent choice for those preferring recovery in familiar surroundings. Services may include skilled nursing, wound care, physical therapy (PT), occupational therapy (OT), or speech therapy, and medication management. Skilled home health is usually a covered insurance benefit if:  ordered by a physician, deemed medically necessary, and you are homebound. Home health qualifications include physician orders, medical necessity, being homebound, and potential prior authorization for private insurances. If home health is the appropriate post-hospital setting, you have the right to be part of the decision as to which agency provides your care.

Private Home Care

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Private Pay Home Care (or Personal Duty Home Care) provides personalized assistance and support for individuals wishing to stay in their homes while receiving necessary care. Unlike insurance-covered home health care, private pay services are directly paid by the individual or their family. These services include help with activities of daily living (or ADLs) like bathing, dressing, grooming, meal preparation, medication reminders, companionship, and light housekeeping. While medical insurance typically doesn’t cover these visits, long term care insurance may apply.

Skilled Nursing Facilities (SNFs)

Skilled Nursing Facilities (SNFs), also known as nursing homes, offer round-the-clock medical supervision and assistance with activities of daily living. SNFs provide a wide range of services, including physical therapy, wound care, and medication management. They are particularly suitable for individuals requiring short-term rehabilitation, extended recovery periods, or long-term care. Skilled nursing facilities are covered by insurance if qualifications are met. If an SNF is the right setting, you have the right to be part of the decision regarding to which facility you are referred.


Hospice Care

Hospice care is a specialized service designed for patients with terminal illnesses, focusing on pain management, symptom control, emotional support, and enhancing the quality of life during the end-of-life journey. Hospice care can be provided in the patient’s home via a home healthcare agency, including an assisted living apartment, or in a dedicated hospice facility or SNF. Typically, hospice care is covered by Medicare/insurance, although Private Home Care services may also be necessary to meet all needs.

Ask What’s Right for You


Navigating the array of post-acute care choices available is crucial for ensuring a successful transition from the hospital. The options mentioned are not mutually exclusive; sometimes, patients may require a combination of options, either concurrently or sequentially. Patients and their families should carefully evaluate their needs and preferences when making decisions about the type of care that best suits their situation. Consulting with healthcare professionals and conducting thorough research can assist in making informed choices and ensuring the highest quality of care during the recovery process. Remember: each option offers unique benefits, and tailoring your choice to your specific needs is key to a successful recovery.

Nonprofit Mary Ann Morse Healthcare Corp. is dedicated to delivering quality, affordable senior living and healthcare services in the MetroWest area – and has been for over three decades. Our mission is to support aging adults and their families by providing a comprehensive continuum of senior living, healthcare, and home care options. Our services encompass assisted living at Mary Ann Morse at Heritage, short-term inpatient & outpatient rehab as well as long-term care at Mary Ann Morse Healthcare Center, and Medicare-certified home health services and private pay personal care by Mary Ann Morse Home Care. We are deeply committed to helping seniors live their best lives and embrace healthy aging, no matter where they are on life’s journey.

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