TIRR’s interdisciplinary team — physicians, physical therapists, occupational therapists, speech-language pathologists, neuropsychologists, and case managers — meets regularly to assess progress toward rehabilitation goals. Discharge is recommended when the patient has achieved maximum benefit from the inpatient intensity of TIRR’s program or when a lower level of care is clinically appropriate. This is a clinical determination, but families can and should participate in team conferences to understand the criteria being applied and voice concerns.

The majority of TIRR patients discharge to home, often with a combination of outpatient therapy, home health visits, and family caregiver support. Patients who cannot yet live independently or who require 24-hour supervision typically transition to assisted living with memory care (for TBI or stroke patients with cognitive deficits), skilled nursing facilities (for those still needing skilled nursing services), or long-term acute care hospitals (for medically complex patients). A smaller subset may transfer to another inpatient rehabilitation facility closer to home.

TIRR case managers can arrange home health services (skilled nursing visits, home PT/OT/speech), durable medical equipment (wheelchairs, hospital beds, grab bars), and referrals to TIRR’s own outpatient rehabilitation program. For TBI patients, TIRR’s outpatient brain injury program offers continued rehabilitation. Family caregiver training is offered before discharge to help caregivers safely manage transfers, medication, and daily activities. Make sure to attend caregiver training sessions — they are one of the most valuable resources TIRR provides.

Stroke patients who cannot return home may transition to assisted living with stroke recovery support, memory care assisted living (if significant cognitive changes occurred), or a skilled nursing facility. The right choice depends on physical function, cognitive status, and care needs. If your family member can direct their own care but needs physical assistance, assisted living with a high level of care may be ideal. If there are significant cognitive deficits, a memory care community provides structured programming and appropriate supervision.

TIRR social workers will work with families to assess the home environment and caregiver availability. If no caregiver is available, TIRR will not discharge a patient to an unsafe home situation — alternatives such as assisted living or skilled nursing placement will be arranged. The social worker can also connect families with professional home care agencies for paid caregiver support. If cost is a concern, MEDICAID HCBS (Home and Community-Based Services) waivers may fund in-home care for eligible patients — ask the social worker to assess eligibility early.

A home assessment visit involves a TIRR occupational therapist accompanying the patient and family to the home before discharge to identify barriers and recommend modifications. This visit can identify needs like grab bars, ramp construction, doorway widening, or bedroom relocation before the patient arrives home. Home assessment visits are not automatically scheduled — families should request one, ideally at least a week before anticipated discharge to allow time for modifications.

Discharge from TIRR to memory care assisted living requires matching the patient’s specific post-TBI or post-stroke cognitive profile to a community equipped to manage it. Not all memory care communities are experienced with TBI — many specialize in Alzheimer’s and other dementias. Ask communities about their TBI or stroke experience specifically. Also ask about staffing ratios, behavioral management approaches, and whether they have access to outpatient therapy. A placement specialist can pre-screen communities and identify those best suited to post-rehab cognitive needs.

Medicare Part A covers SNF care following a qualifying inpatient hospital stay of at least three days. A stay at TIRR counts as a qualifying inpatient stay. Medicare covers up to 100 days in a Medicare-certified SNF per benefit period: days 1-20 at 100%, days 21-100 with a daily copayment (in 2024, $194.50/day). Coverage requires daily skilled service — as soon as therapy or nursing is no longer considered “skilled,” Medicare coverage stops. Medicare Advantage plans follow their own authorization rules, which often result in shorter covered stays.

Ideally, discharge planning conversations should begin within the first week of admission. Placement options for post-TIRR care — especially memory care or assisted living — often require 48 to 72 hours to arrange, and some facilities have waitlists. The earlier the planning begins, the more options are available. TIRR case managers are typically proactive about this, but families should also be initiating these conversations rather than waiting to be contacted.

Erika specializes in exactly the kind of post-rehabilitation placement that TIRR patients need: identifying assisted living, memory care, or specialized senior care options that can support continued recovery. She understands the difference between a facility that accepts TBI patients and one that is genuinely equipped to care for them. She can tour facilities on your behalf, arrange admissions quickly when TIRR sets a discharge date, and serve as a sounding board as you navigate the decision. Her consultation is free.