⚠️ WARNING SIGNS: PATIENT FAILING HOME HEALTH SERVICES
When to Request an IRF Evaluation for Patients at Home
Key Insight: Some patients discharged to home health may not be progressing as expected or may be declining. These patients may benefit from intensive inpatient rehabilitation. Early identification can prevent hospital readmissions, falls, and further functional decline.
🚨 KEY WARNING SIGNS TO IDENTIFY
1
No Functional Progress
Patient shows little or no improvement in mobility, transfers, or ADLs after 2-3 weeks of home health therapy.
2
Declining Function
Patient is getting weaker, less mobile, or losing abilities they previously had. Walking distances are decreasing.
3
Recurrent Falls
Patient has fallen multiple times at home, or has had near-falls requiring assistance to prevent injury.
4
ER Visits / Readmissions
Patient has been to the ER or readmitted to the hospital since discharge, especially for fall-related injuries or weakness.
5
Unable to Perform ADLs Safely
Patient cannot safely bathe, dress, toilet, or transfer without significant assistance despite home health services.
6
Increased Medical Complexity
New medical issues have emerged (infections, cardiac events, respiratory problems) requiring closer monitoring.
7
Caregiver Burnout / Inability
Family/caregiver is overwhelmed, exhausted, or physically unable to provide the level of assistance needed.
8
Therapy Intensity Insufficient
Patient needs more therapy than home health can provide (typically only 2-3 visits/week vs. 15+ hours/week at IRF).
🔴 IMMEDIATE RED FLAGS - REQUEST EVALUATION NOW
- Multiple falls in the past 30 days
- Unable to get out of bed without maximum assistance
- Significant weight loss or signs of malnutrition
- New onset confusion or cognitive decline
- Caregiver states "I can't do this anymore" or "We need more help"
- Patient expresses fear of falling or being alone
- Wound complications or skin breakdown from immobility
📋 SCREENING QUESTIONS TO ASK FAMILIES & HOME HEALTH AGENCIES
"Has the patient improved since starting home health?"
"How many times has the patient fallen in the past month?"
"Can the patient walk to the bathroom safely?"
"Is the patient able to bathe and dress independently?"
"Has the patient been to the ER since discharge?"
"Is the caregiver able to manage the patient's needs?"
"Is the patient eating and drinking adequately?"
"Does the patient feel safe at home?"
✅ NEXT STEPS: REQUEST AN IRF EVALUATION
1
Contact UMRH
Call our admissions team to discuss the patient's situation
2
Schedule Evaluation
Our clinical liaison can evaluate the patient at home or via telehealth
3
Coordinate Transfer
If appropriate, we'll work with the PCP to arrange direct admission