When “Going Home” Feels Like the Only Option

What used to be hardest to manage was an unplanned discharge. Lately, something different is happening: families are actively pushing to go home earlier than recommended. And that shift matters in how we handle discharges.

It raises important questions about why families want to leave sooner and what that choice means for patients, caregivers, and loved ones.

Why do families want to go home early? 

Some of these questions are uncomfortable but necessary for the healthcare industry to reflect on:

• Has the quality or availability of rehab changed?

• Are staffing shortages affecting recovery?

• Are staffing shortages affecting clients' well-being?

• Have we, as an industry, become so risk-averse around falls that mobility is limited in ways that actually slow progress for the people receiving care?

  
  

What does this look like for patients and families? 

In reality, many care partners don’t have the time or space to reflect on the why.

They are focused on the immediate now questions:

• What do we do next?

• How do I get my loved one home safety where they are happier?

• Who should we be talking to?

  
  

When families are navigating discharge this way, leaving early doesn’t feel like a choice; it feels like the only option.

The Real breakdown is often Not Medical Its Systematic

Patients are being discharged with higher-acuity needs at a time when care coverage is limited, and costs are rising. Families often travel across state lines or take unpaid time off work simply to be present for critical moments, such as specialist visits that took months to schedule. Or the discharge home from the hospital or rehab.

It's important to note that the system and the people within it are already exhausted.

Compounding this strain, much of the housing stock in the Northeast was never designed to support recovery at this level. As a result, the transition from medical care to daily functioning has become increasingly fragile.

Healthcare and the home are still treated as separate systems, even though in reality they function as one. When communication breaks down, families are left making high-stakes decisions with incomplete information and conflicting assumptions. They face a maze of services, with little clarity on what support is available, how to access it, or who is responsible.

This is where preventable setbacks occur.

What Families Are Actually Trying to Figure Out

Most families are not asking for miracles. They are asking for clarity, direction, and reliable solutions.

In the first weeks at home, the questions are practical and urgent:

• What needs to change immediately versus later?

• What support is realistically available at home?

• What can be trialed temporarily without overcommitting resources?

• Who is responsible for what once formal rehab ends?

Three Things Families and Care Partners Can Do Right Now

This is the information I wish families were given before discharge when there’s still time to plan, not just respond.

1. Separate safety from permanence. Not every modification/adaptation to get someone home needs to be final. Temporary ramps, grab bars, bed adjustments, or room changes can stabilize the situation while better decisions are made.

2. Clarify the scope of home care services early. Home care PT, OT, and nursing play an important role, but they are time-limited and task-focused. Understanding what they can and cannot address helps families plan instead of react. Home Care cannot, and does not make the home as safe as a consultation with a case manager or accessibility specialist might. They are necessary, and play a role, but they are focused on medical stability and basic function, NOT long-term, or ongoing success. Things are changing often, and unfortunately, the social worker in the rehab may not know what the services outside of rehab ACTUALLY look like.

3. Evaluate the home as a system, not a room. Falls and fatigue are rarely about one feature. They are about how movement, routines, and environment interact across the whole home. Talking about the whole system helps with identifying the issues at hand. Is someone walking without their walker because they have cognitive deficits? Or are the hallways too narrow for the walker? Is this something the rehab specialist from Home Care can address? Or is this something we need to consider long-term?

These mindset shifts and steps do not solve everything. But they prevent small gaps from becoming major crises. Because the truth is, families do not fail because they lack effort. They struggle because systems hand off responsibility without a shared understanding from all parties involved.

When we do better at that moment, everything downstream improves.