title:Leaving the Hospital, Going To the Nursing Home

| Thursday, October 20, 2011
By Bobby Lee

author:Tammy Gonzales


date_saved:2007-07-25 12:30:09



Admitting your self or somebody you love to a nursing home for rehabilitation is something that we need to do and not what we want to do. As we age the chance increases for a health accident even if we're healthy. Unfortunately, nat all of the care we will need can be supplied in a hospital or at a rehabilitation specialty center. Some of us will need to go to a competent 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 talk about 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 should 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 also 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 objective is to create a safe discharge plan to suit the requirements of the patient.

For the aged and for people with multiple disease progressions the recommendation perhaps for the patient to be admitted to a long-term care facility (nursing home) that offers qualified nursing and rehabilitation. The hospital Discharge Planner generally offers a list of nursing homes that they are contracted with or offer dependable service for you to tour and choose. The discharge planner won't choose for you. I recommend that you take the time to see at least 3 nursing homes for the following reasons:

To find out if environment is favorable to your patients needs and comfort levels.

Bed availability. Some skilled units have 2 bed rooms, 3 bed rooms and four bed rooms.

Do they have the competent staff to provide the services required? Physical therapist, occupational therapist and speech language pathologist.

Responsiveness of nursing staff. Are they staffed? Do they respond promptly?

Observe resident in the nursing house. Are they clean? Are the staff mindful of them?

Once you make the choice 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 offer the care and has the appropriate equipment for the patient as well as get the needed info to ensure that the patient has met Medicare criteria for a skilled rehabilitation stay and to obtain info to ensure the payer source.

This info is then passed on to the nursing home's Admissions Coordinator to review. As soon as 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 confirm 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 validating the payer source. If the payer source is traditional Medicare they will validate the days available that Medicare will pay for. If, an HMO is the payer source they'll obtain required authorization, level of care and the days authorized to provide care. The Admissions Coordinator will disseminate all the hospital info 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 ought to be ready with all of the essential 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 is not a hospital, nor home for a skilled patient.

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