Near end of your or your loved ones hospital stay, you will be contacted by Discharge Planner or Case Manager of hospital to discuss alternatives of continued care. You or your loved one may no longer meet 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 hospital will assess needs of patient’s care based on acuteness of care and monitoring required for patient, patient’s rehabilitation potential, ability of patient or their family’s ability to care for patient and nature of home environment that supports patient. In all cases, goal is to establish a safe discharge plan that meets needs of patient.

For aged and for people with multiple disease progressions recommendation maybe for 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 time to see at least three nursing homes for following reasons:

The day that resident is received at nursing home skilled rehabilitation unit resident or responsible party will be offered a list of physicians to select one that will follow them during their stay. When a physician is selected nurse will contact him/her to receive resident. The nurse will receive report from hospital nurse to verify discharge orders from hospital physician and condition of resident.

The first day (all time before midnight) at nursing home is called day of rest (day 1 of skilled care). No therapies or therapy evaluations will be offered on this day so that resident can become adjusted to routines and staff.

The Admissions Coordinator will meet with resident or resident’s representative (responsible party or Power of Attorney) to do Admissions Agreement and collect financial and health related information and to disseminate information on their nursing home’s policy’s and procedures. Nursing homes must meet federal, state and local regulations therefore they will have several acknowledgement forms that require signatures of receipt. These forms vary from state to state and nursing home to nursing home.

Most all nursing homes have an Admission Agreement and it must be signed within 24 hours of admission. Most of agreements are comprehensive and are written to accept residents with varying levels of care and payer sources. The agreement explains what nursing homes responsibilities and limitations are and what resident/responsible party’s responsibly and limitations are.