Study's purpose is to determine if a patient's perception of readiness for discharge from sub-acute rehabilitation, as measured by Readiness For Hospital Discharge Scale Patient Self-Reports Form, correlates with the patient's success after discharge, measured by patient reported number of falls, emergency room visits and hospitalizations 30 days post discharge.

All sub-acute rehabilitation patients will be approached for study participation one day prior to discharge day from the facility. Patients will be approached in their private room within the facility to obtain consent. Consent will be reviewed with patient by investigators. Patients will be asked to demonstrate understanding of the study and what consent will imply utilizing the teach back method. If patient is able to demonstrate understanding and gives consent the MoCA will be administered. If MoCA scores falls between 22-30 they will be included in study. If MoCA score falls below 22 they will not be included in study and that will be explained to them at that time. MoCA scores will be included in patient medical record. Patient name and assigned ID number, phone number, second contact and consent will be recorded on the confidential roster sheet and stored in a locked file cabinet located in director's office at Peconic Landing. The day of discharge patients will complete the RHDS survey. Investigators will complete the study data sheet including ID number, MoCA score, RHDS score, length of stay, discharge date, and recommended discharge therapy- home care, outpatient, none. Thirty to thirty-seven days after discharge investigators will call patient and ask 3 questions from scripted form. "How many falls have you had since discharge home:, "How many visits to the emergency room have you had since your discharge home","How many admissions to the hospital have you had since your discharge home." Following completion of telephone questions, confidential roster sheet and consent form will be shredded.

Inclusion Criteria:

Montreal Cognitive Assessment score 22 or greater

• consent with observed teach back confirmation
• discharge from sub-acute rehabilitation

Exclusion Criteria:

• Montreal Cognitive Assessment score less than 22
• inability to "teach back" during consent process
• non english speaking

Older adults discharged from a sub-acute rehabilitation facility

Data Collection sheet