When Mom finally came home from the rehab facility, we expected progress — or at least stability. After all, she’d spent nearly two months there following her hip fracture, receiving occupational therapy, physical therapy, and speech therapy. We assumed there would be a care plan, measurable goals, and ongoing communication to ensure she was regaining strength. What we didn’t expect was to find her weaker than before she went in.
The Reality of “Rehab”
During her stay, we raised concerns about the lack of communication from staff and the absence of a clear care plan. We asked questions about therapy goals, progress notes, and nutrition—especially when we noticed her meals were heavy on carbs and light on protein. Each time, we were reassured that “she’s doing fine.”
But “fine” turned out to mean “barely maintaining.”
When Mom came home, it became painfully clear that there had been little to no progress. Her mobility had declined. Her strength was diminished. Tasks she could manage before — standing, pivoting, even feeding herself comfortably — were now struggles. It wasn’t neglect in the dramatic, headline sense. It was neglect in the quiet, procedural sense — a system so stretched and impersonal that patients slip through the cracks without anyone noticing until they’re home again.
Distance and Dilemma
We hate that we couldn’t be more involved. The facility was over an hour away — the only one her insurance would cover that could accept her. We did what we could: visits, phone calls, and advocating remotely. But distance limits your influence.
You can’t pop in for a surprise visit. You can’t see what’s left on her tray after meals. You can’t observe therapy sessions or ask the therapist questions in real-time. And while we were juggling our own responsibilities — jobs, home, and caregiving coordination — the gap between what we hoped was happening and what wasn’t happening widened.
The Insurance Catch
One of the most frustrating realities for families in our situation is how insurance dictates care. It often determines where your loved one goes, how long they stay, and what services they receive — sometimes more than their medical needs do.
“Coverage” doesn’t always mean “quality.” The facility that accepts your plan may not be the one that provides the best care. It’s an awful truth: access to good rehabilitation often depends on what your insurance deems “medically necessary,” not what’s actually necessary for long-term recovery.
Starting Over at Home
So here we are again — rebuilding from the ground up.
Home health services have begun: physical therapy, occupational therapy, and nursing support. It’s familiar territory now, though bittersweet. Each session is a mix of progress and frustration, both for Mom and for us. We’re trying to regain what was lost during her time in “rehab.” Her body lost muscle. Her confidence faltered. And our trust in the system took another hit.
Still, home feels different. Hopeful, maybe. We can monitor her nutrition now — make sure she’s getting enough protein, staying hydrated, and supported emotionally. We can advocate daily, not from a distance. It’s slower than we imagined, but progress, in any form, is sacred.
Advocacy: What We’ve Learned
If you find yourself walking this same path, here are a few lessons we’ve learned — often the hard way:
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Ask for documentation. Every patient should have a care plan with goals and progress notes. Request copies regularly.
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Track nutrition. In rehab facilities, meals may meet calorie minimums but not nutritional needs. Ask about protein intake and supplements.
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Stay involved — even from afar. Schedule check-ins with therapy staff, nurses, and case managers. Document every conversation.
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Know your rights. Medicare and private insurance plans have grievance processes for inadequate care. File a complaint if needed.
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Plan for discharge early. Before your loved one comes home, insist on a discharge plan that includes therapy frequency, safety assessments, and equipment needs.
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Lean on local resources. Area Agencies on Aging, hospital social workers, and nonprofit caregiver networks can connect you with advocacy help, financial support, and home care programs.
Resources for Caregivers and Families
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The National Institute on Aging (NIA): www.nia.nih.gov/health/caregiving
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Family Caregiver Alliance: www.caregiver.org
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Centers for Medicare & Medicaid Services (CMS): www.cms.gov
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Eldercare Locator: eldercare.acl.gov
These organizations offer guidance on patient rights, home health regulations, and advocacy tools for families navigating the system.
A Bittersweet Homecoming
Bringing Mom home was supposed to be the victory lap — the reward for enduring the hardest part of recovery. Instead, it feels like we’re back at the starting line. But there’s something beautiful in that, too. We have a second chance to do it differently, to ensure she receives the care she deserves, to speak up louder and stand firmer.
And that’s what raising our parents often means — learning, advocating, and loving through every imperfect, uphill step.
