Leaving the Hospital, Going To The Nursing Home

Near the end of your or your loved ones hospital stay, you will be contacted by the Discharge Planner or Case Manager of the hospital to discuss the alternatives of continued care. You or your loved one may no longer meet the criteria for a hospital stay. Once a patient is stable they must be moved towards a lower level of care.

The Interdisciplinary Care Team of the hospital will assess the needs of the patient’s care based on the acuteness of the care and the monitoring required for the patient, the patient’s rehabilitation potential, the ability of the patient or their family’s ability to care for the patient and the nature of the home environment that supports the patient. In all cases, the goal is to establish a safe discharge plan that meets the needs of the patient.

For the aged and for people with multiple disease progressions the recommendation maybe for the patient to be admitted to a long-term care facility (nursing home) that provides skilled nursing and rehabilitation. The hospital Discharge Planner usually provides a list of nursing homes that they are contracted with or provide reliable service for you to tour and select. The discharge planner will not choose for you.

I recommend that you take the time to see at least three nursing homes for the following reasons:

To find out if environment is conducive to your patients needs and comfort levels.
Bed availability. Some skilled units have 2 bed rooms, 3 bed rooms and 4 bed rooms.
Do they have the skilled staff to provide the services required? Physical therapist, occupational therapist and speech language pathologist.
Responsiveness of nursing staff. Are they staffed? Do they respond in a timely manner?
Observe resident in the nursing home. Are they clean? Are the staff attentive to them?

Once you make the selection the Discharge Planner will check for bed availability at that nursing home. The nursing home may send out their nurse liaison to the hospital to assess the resident and make sure that the nursing home can provide the care and has the appropriate equipment for the patient as well as get the needed information to verify that the patient has met Medicare criteria for a skilled rehabilitation stay and to obtain information to verify the payer source. This information is then passed on to the nursing home’s Admissions Coordinator to review. Once it has been decided that the nursing home will accept the patient the Discharge Planner is contacted. The Discharge Planner will obtained the necessary physicians orders to discharge the patient to the nursing home and make the transportation arrangements. As a courtesy to the nursing home sometimes the Discharge Planner will fax the orders on to the Admissions Coordinator so the receiving nurse can verify the equipment needed and order the medications required for the patient. Otherwise, the orders come with the patient.

While at the nursing home the Admissions Coordinator is verifying the payer source. If the payer source is traditional Medicare they will verify the days available that Medicare will pay for. If, an HMO is the payer source they will obtain required authorization, level of care and the days authorized to provide care. The Admissions Coordinator will disseminate all the hospital information to the Interdisciplinary Team of the nursing home to prepare to receive the patient.

By the time the patient arrives at the nursing home the room should be ready with all of the necessary equipment needed. The Admissions Coordinator will have an agreement ready for the patient or the responsible party to review and sign. Once in the nursing home the patient is referred to as a “Resident”. The nursing home is a different environment. It’s not a hospital, nor home for a skilled patient.