Leaving the Hospital, Going To The Nursing Home
Admitting yourself or someone you love to a nursing home for
rehabilitation is something that we have to do and not what we
want to do. As we age the risk increases for a health accident
even if we are healthy. Unfortunately, nat all of the care we
will ned can be provided in a hospital or at a rehabilitation
specialty center. Some of us will need to go to a skilled unit
at a 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.