By Nikki Tyler
Sometimes, a hospital stay is only the first step in your loved one’s recovery.
After a fall, fracture, cardiac event or another unexpected medical emergency, many patients are not ready to return home immediately. Instead, they may need a short-term stay at a skilled nursing facility for rehabilitation. In more complex cases, they may require long-term care.
For families, navigating the next steps can feel overwhelming. How do you choose the right facility? What does the placement process involve? Understanding how it works before you’re faced with these decisions can help reduce stress during an already difficult time.
Start With the Hospital Social Worker
Your first point of contact is the hospital social worker, who coordinates your loved one’s discharge plan and helps arrange placement after they leave the hospital.
Be open about where you would like your loved one to receive care. The decision ultimately belongs to you and your family.
Typically, the social worker will ask you to identify your top five facility choices. When making your selections, families often consider factors such as location, reputation, previous experience with the facility, and specialized services.
Keep in mind: You are not required to choose a rehabilitation center that is affiliated with the hospital unless you prefer to do so or no other appropriate options are available.
How the Referral Process Works
Once you’ve identified your preferred facilities, the hospital social worker sends a referral to each one. The referral package includes the patient’s demographic information, insurance and financial details, medical records from the hospital stay, and any documentation required by New York state.
Each facility’s admissions department then reviews the referral. The admissions team determines whether they can accept the patient based on several factors, including:
• Whether the facility can meet the patient’s clinical needs
• Current bed availability
• Whether the facility accepts the patient’s payer source, such as Medicare, Medicaid, private pay, or long-term care insurance
Stay Involved and Advocate
As your loved one’s advocate, don’t hesitate to contact the admissions department at your preferred facility to confirm that the referral has been received. If it hasn’t, notify the hospital social worker so the issue can be addressed promptly.
Making that personal connection with the admissions team can also be helpful. Letting them know you’re interested in their facility and that a referral is on the way helps keep communication open throughout the process.
When More Than One Facility Accepts
If one or more of your preferred facilities accepts the referral, the admissions team will notify the hospital social worker, who will then contact you.
If multiple facilities are available, you’ll have the opportunity to choose the one that best meets your loved one’s needs. Once you’ve made your decision, arrangements will be made for the transfer following hospital discharge.
If Your Preferred Facility Isn’t Available
Not every referral results in an acceptance, and that can be disappointing.
If your first choice — or even several of your top choices — is unable to accept your loved one, ask the hospital social worker why. There may be legitimate reasons, such as a lack of available beds, the facility’s inability to meet the patient’s medical needs or insurance limitations.
It’s important to stay engaged, ask questions and make sure you understand the reasons behind the decision. This is an important transition and your loved one is counting on you to help make informed choices.
While it can be frustrating not to secure your preferred facility, remember that the hospital social worker’s goal is to help find the safest and most appropriate care available based on your loved one’s needs and the options currently available.
Planning Ahead for Scheduled Hospital Stays
Not every hospital stay is unexpected.
If your loved one is scheduled for surgery or another planned medical procedure, and you know they will need rehabilitation afterward, consider contacting your preferred rehab facility before the hospital stay.
Pre-planning allows the admissions team to prepare for your loved one’s arrival and, when possible, reserve a room in advance. Be sure to let the hospital social worker know that you’ve already made arrangements.
Planning ahead can simplify the discharge process and provide valuable peace of mind for both you and your loved one.
Nikki Tyler is the director of admissions for St. Ann’s Community. She can be reached at ntyler@mystanns.com, or by calling 585-697-6507