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I used to be a secretary for our local Visiting Nurses. When one of our patients was in the hospital, I would get a call asking what we could do when they were released. My answer was that a Social Worker should talk to you before the patient is released. She will explain the patients options. If going to rehab or having OT, PT at home. Another nursing agency usually will not come in if one is already there. When going into the rehab, all financials should be discussed with the patient and paperwork signed showing who is going to pay the balance. If the patient is not able to sign, then the person holding the medical POA can do this.
Now, I had a problem with Mom's last hospital stay. She was showing signs of Dementia and with dehydrating herself, it was worse. I asked that no nurse or doctor discuss her care with her. That I was to be called. I came in one day and there were two nurses (one being a student I think) discussing what they would be doing. The nurse was talking fast and I told her "you lost her back on the first word". Mom went to the rehab my daughter works at so this didn't happen. My daughter is second on the medical so they talked to her. If she was off duty, they called me. Make sure you know all medications they are giving the patient. Mistakes have been made going from hospital to rehab. My Uncle was in the hospital for a reaction to a med and transferred to rehab where that doctor recommended it. TG my uncle/Aunt asked questions or he would have died. Hate that doctors in hospitals and rehabs don't confer with the patients primary or specialist.
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