Care transitions
"She fell, she's in rehab, and they're saying she can't go home."
If that's where you are right now, take a breath. You have more time and more options than it feels like — and you don't have to sort this out alone.
It usually starts with a phone call you weren't expecting. A fall in the bathroom. An ambulance. Two days in the hospital, then a transfer to a rehab center with a name you've never heard of. Everyone is kind, everyone is busy, and nobody sits down and explains the whole picture.
Then a case manager mentions that Medicare days are running out and asks what your discharge plan is — as if you were supposed to have one.
This is the moment most families find us. Not because they're unprepared, but because nobody prepares for this. Our whole job is to guide you through the next two weeks — explaining the options and helping you weigh them — so the decision you make is one you can live with.
What's actually happening, in plain language
- Medicare typically covers up to 100 days of skilled nursing rehab per benefit period — but only while your parent is still making measurable progress. Coverage often ends far sooner than 100 days, and it can end with only a couple days' notice.
- "Can't go home" usually means can't go home safely alone. With enough help at home, home is sometimes still possible.
- The list of facilities a case manager gives you is required to be neutral. It is not a recommendation, and it isn't filtered for cost, quality, or whether they even have a bed.
- You have the right to appeal a discharge decision, and you have the right to take a few days to decide. Ask for the written notice.
- Assisted living is not covered by Medicare. Knowing how you'll pay changes which options are realistic, so it's worth sorting out early.
What we help you figure out
- What level of care your parent likely needs now — and what they may need in six months.
- Whether going home with in-home care and safety modifications is realistic for your situation.
- Which communities may have an open bed, accept your parent's care needs, and fit your budget.
- How you might pay: private funds, long-term care insurance, VA Aid & Attendance, or a home sale.
- What to ask the discharge planner, the therapists, and each community you tour.
- Who to call for the logistics — movers, the house, the estate sale — from providers we know and have vetted.
- How to keep siblings in three states on the same page without another argument.
If discharge is days away, call us now
We can often help you build a realistic shortlist the same day, and we'll meet you at the hospital or rehab center if that helps.
Call (801) 631-8569Where this usually leads
You don't have to figure this out in a hospital hallway.
One call, one person, and enough clarity to explain the plan to the rest of your family tonight.