The “What Next?” Phase: When Home Health Comes In
Coming home from skilled nursing felt like progress.
Grandpa was stronger. He was medically more stable. He was back in familiar surroundings.
But getting home did not mean caregiving became easier.
It meant the next phase had begun.
Home health care came in to continue the therapies he had started in skilled nursing. They reviewed his medications again, helped simplify the medication process, and reinforced the things we had already been learning about routine, safety, hydration, nutrition, and strength.
One of the most helpful things we did was simplify the pharmacy situation.
One pharmacy.
Ninety-day refills when appropriate.
Coordinated refill dates.
And medication delivery.
That may sound like a small thing, but it was huge for me.
I was still working. I had two boys, one in junior high and the other in high school. I had a husband, a household, and all of the responsibilities that came with my own life.
And Grandpa lived about 45 minutes away.
I made sure I was there most mornings from about 7:00 to 9:00 before my workday began, and I tried to arrange my schedule so I could be available when home health came.
Looking back, I don't know that I recognized just how much I was carrying.
I was granddaughter.
Care coordinator.
Medication manager.
Appointment scheduler.
Family communicator.
Financial problem-solver.
And somewhere in there, I was still supposed to be a wife, mother, employee, and human being. Talk about caregiver burnout and it happened quick...
Home health is more than therapy
Families often think of home health as nursing, physical therapy, or occupational therapy.
Those services can be incredibly important, but there may also be other members of the team.
Depending on the program and the person's needs, that can include a social worker.
Because of my professional background I already knew how to navigate many resources.
But I want families to know those supports exist and as an expert in this field, I should've asked for help. I know that now and I will not repeat this mistake!
A social worker can be especially valuable during that “What happens next?” stage.
They may help families understand available community resources, talk through caregiver stress, identify transportation, housing, in home primary care or other in-home support options, connect families with benefits or financial-assistance resources, help with long-term-care planning, facilitate family conversations, explain levels of care, and help organize the many questions that suddenly seem to arrive all at once.
Sometimes what a caregiver needs most is not another task.
It is another person who understands the system and can help carry part of the planning.
And I needed that too.
I could not carry all of it myself.
Even with my professional experience, I knew I needed another layer of support.
I asked Grandpa's medical team about a referral to palliative care.
Not because we were giving up.
Because I needed help with the weight of it all.
Education.
Planning.
Goals.
Family meetings.
Anticipating what might come next.
I didn't want every decision resting on one person's shoulders.
We also scheduled an appointment with his primary care provider because there were additional evaluations and orders we needed to discuss, including a neuropsychological evaluation.
That evaluation would become its own chapter in our story.
At this point, what I needed was a clearer understanding of Grandpa's cognitive abilities and decision-making capacity so we could determine what legal and financial steps were appropriate. A neuropsychological evaluation can provide important information, but the authority to manage another person's finances depends on the legal documents and circumstances in place—not on the evaluation alone.
And finances were quickly becoming one of our biggest problems.
Then the bills started telling their own story.
We began finding past-due bills.
More problems with the house surfaced.
The stove stopped working.
Then the microwave went out.
Something always seemed to need repairing, replacing, paying, or figuring out.
And eventually I had to acknowledge something I desperately wished were not true:
I could not afford to financially maintain two households.
I had my own family's bills.
Grandpa had his.
And love does not create an unlimited bank account.
That realization was painful.
It also began to ruffle feathers.
Because once finances become part of caregiving, the conversations change.
Can he continue living here?
What can we afford?
Should something be sold?
What resources are available?
Who should pay for what?
How much help can family realistically provide?
And perhaps the hardest question:
What happens when what someone wants is no longer financially or practically sustainable?
Those conversations can make family members uncomfortable.
They can create disagreement.
They can make the person doing the day-to-day planning look controlling when, in reality, that person may simply be staring at the numbers everyone else would rather not look at yet.
I was beginning to understand that caregiving wasn't just about helping Grandpa remember his medications or making sure he went to therapy.
It was about building an entire system around him.
Medical care.
Home care.
Medication management.
Legal planning.
Finances.
Family responsibilities.
Safety.
Future needs.
And every time we completed one step, another one appeared.
That was the lesson of home health for me:
Getting someone safely home isn't the end of discharge planning.
Sometimes, it is where the real planning begins.
And our next step was going to require us to look much more closely at Grandpa's memory, his ability to manage his affairs, and what our family would need to do next.
To find a great home health care agencies near you, you can use this website:
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