Discharge Plans

Every discharge plan is different and reflects a patient’s unique personal and social situation. Recovery from a brain injury takes months and even years, so after discharge most people will require ongoing therapy. Discharge plans fall roughly into one of four categories:

  • Discharge Home, with Referral for Home-Based Rehabilitation Services: This discharge plan is appropriate for individuals who are well enough to be at home, but who are not well enough to travel for therapy. The individual’s social worker will typically make a referral to a nursing agency that will visit the individual at home to assess their needs. The nursing agency will also provide needed services which may include physical and occupational therapy and a home health attendant. It is important to note that family is almost always needed to provide some of the help that the individual will require at home.
  • Discharge Home, with Referral for Outpatient Services: This discharge plan is appropriate for individuals who are well enough to be at home and able to travel to an outpatient clinic for therapy. Family members will provide the individual with all needed help and supervision at home, and the individual’s rehabilitation therapies will be provided through the most convenient outpatient clinic.
  • Discharge to a Residential Brain Injury Rehabilitation Program: This discharge plan is appropriate for individuals who are well enough to live in the community but require a supervised and structured environment. This option is generally best for individuals who do not need inpatient supervision by a nurse or physician but may benefit from continued therapy to help the transition back into the community. The availability of these programs varies based on insurance type and where you live.
  • Discharge to a Nursing facility: This discharge plan is appropriate for individuals who are not yet ready to return home and who would benefit from continuing their rehabilitation therapies in a structured environment with nursing care. The nursing facility can provide nursing care and ongoing rehabilitation therapy in specialized rehabilitation wings (subacute rehabilitation), usually for up to three months. Length of stay varies based on medical need, degree of progress in that setting, and availability of rehabilitation benefit. If an individual’s team recommends a nursing facility that provides subacute rehabilitation, the social worker will help the individual find one that meets the individual’s needs.