Dad Had a Stroke… Now What?

Mr. Smith is 79 years old. A week ago, he had a stroke while home alone. Thankfully, his youngest son arrived minutes later and got Mr. Smith admitted to the hospital.

After a week, the hospital discharge planner contacted Mr. Smith’s oldest son, Paul, who is listed as his healthcare POA (Power of Attorney). The discharge planner emailed Paul a list of rehabilitation facilities. He was to select the top three places in order of preference for his father’s rehabilitation. Paul would need to make his selections by the end of the day, as the plan was to move Mr. Smith the following day. Naturally, Paul was overwhelmed; he wanted to pick the best place for his dad but had no idea what any of these places are like. One place is listed as a nursing home; another as  a health care campus. What are the differences? A nursing home is the last place Paul wanted his dad to be.   

First, it is helpful to understand the terminology. It can be very confusing, as multiple words are used interchangeably to describe similar services and places:  Skilled Rehab, Skilled Nursing Facility, Long-Term Care Facility Continuum Care Campus (CCC), Health Care Campus. Generally, all these places offer skilled rehabilitation services in addition to long-term care. Further, some offer Independent Living, Assisted Living and Memory Care. 

Skilled Care and rehabilitation typically refer to inpatient, medically necessary services offered by licensed nurses, physical, occupational and/or speech therapists. Skilled services or rehabilitation are temporary, time sensitive and expensive. Usually, rehabilitation is partially covered by Medicare, Medicaid and private/supplemental insurance.

When patients arrive at a facility for rehabilitation, they are assessed by the skilled services team, often referred to as the therapy department (PT, OT, speech and nursing). The therapy or skilled team determines the person’s needs and goals. A plan is developed to meet the intended goals within a determined period. An individual will either progress, stay the same or decline. 

Let’s suppose that Mr. Smith has made little progress after three months of rehabilitation services at a Skilled Nursing Facility. He remains paralyzed on his left side and requires assistance to do most things… getting dressed, hygiene, cutting food, getting in and out of bed. All these activities are referred to as Activities of Daily Living (ADLs).  

At this time, Mr. Smith will no longer qualify for skilled services or rehabilitation. He still is not able to go safely home, as his needs are too great. He will now require what is called custodial care. Custodial care means an individual needs assistance with ADLs but does not require or qualify for skilled care or services. A caregiver/aid can provide custodial care to meet all his ADLs, and his ongoing medications and medical needs will now be considered part of his custodial care needs. Mr. Smith has completed his rehabilitation and is now moving into a long-term care situation.  

 Long-term care refers to a facility providing custodial care. Individuals for many different reasons are not able to receive custodial care safely in their homes, therefore require a long-term care facility (often called a nursing home). Long-term care facilities offer services which include Skilled Rehabilitation. Mr. Smith started out in short-term skilled rehab. After a period, he no longer showed improvement, despite receiving skilled services (physical, occupational and speech therapies). He then required custodial care. His family would not be able to safely provide the care he continued to need 24/7. 

Mr. Smith then “moved” to Long-Term Care within the same facility. Sometimes a facility will divide their building into sections with skilled services and rehabilitation in one area and long-term care in another. Others may provide skilled care and when the person requires ongoing custodial care, those services continue in the same room. What changes between skilled rehabilitation and long-term care are the type of services and costs? 

The first step in making informed choices about where to go for rehabilitation is to understand the differences in services offered at a facility. Other considerations include: What happens if a person is not able to return home after receiving skilled therapy services? Are long-term care services or custodial care offered and what are the costs? We will tackle these questions in next month’s blog entry, when Mr. Smith cannot return home and settles into Long-Term Care.

About the Author:  Jennifer Beach, LSW, MA, C-SWCM established Advocate for Elders in Rocky River in 2010. Jennifer has 25 years of experience in working with and advocating for older adults and their families. Jennifer is a licensed, insured Social Worker and an Advanced Aging Life Care® Professional. She has served as the Midwest Chapter President of the Aging Life Care Association and additionally served 7 years on the Board of Directors. In 2018, Jennifer was honored as the recipient of the ALCA Midwest Chapter Outstanding Member of the Year Award. Learn more at

Jennifer is also a monthly contributor and author of Caregiver Corner for Northeast Ohio Boomer and Beyond blog and magazine.