Aftercare after hospital discharge - Isn't this how all hospitals work?
Just curious because this question comes up often. I also got this question a lot when I was secretary for a Visiting Nurse Assoc. I live in South Jersey. When a person is hospitalized and needs rehab the Hospital handles it. They have a special employee that calls around to see where beds are available and then gives the patient or family members a choice. At no time have I had to call around asking if an opening is available. Homecare I picked which one I preferred, but the hospital called the service and sent them the doctor order. Then Homecare calls me to set up a day to admit my Mom. As a secretary I got lots of calls from family members freaking out because they thought the responsibility would be theirs. I explained that a Social Worker would contact them with how discharge will be handled. As a VNA facility we did nothing until we had a doctors order in hand from the hospital. Isn't this how all hospitals work?
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Thank you for agreeing with me Myownlife.
The hospital can't discharge anyone to a nursing home without their permission. Or, if the person isn't capable, the permission of whoever holds durable power of attorney. They might want her to go to a rehab unit or a skilled facility for physical therapy following a fall, but that should be a short term admission. If she prefers not to do that, home health care can have nurses or physical therapists go to her home probably 2-3 days a week for PT. So long as she has a "skilled" service coming to her home she can also have a home health aide who can help with bathing, dressing, etc. All this is covered under Medicare!!
I have to say what happens to the parents who just go home after any hospital stay and THEY LIVE ALONE. They are already in a weakened state from being bedridden, it's going to take a while to get their strength back, who is doing meal prep?, med minder?, and then comes along a fall.
Myownlife is right. As long as the patient understands the Hospital will not be responsible for what happens to the patient after discharged, the patient can decide what he/she wants to do. Some hospitals will try to use phrases like "The doctor's feel he/she is too weak.." to try to persuade the patient to go to rehab.
I learned something reading this thread! Times are changing!
Our impression was that it was up to us to find a place and we had 48 hours to do it. We dealt directly with the rehab facility and the case manager there coordinated with the hospital case manager but, in reality, we had to find the facility with no guidance or information about the places on the list from the case manager. It was very stressful!
As far as discharge from rehab is concerned medicare's standard time allowance is 20 days although under special circumstances the therapy can be extended but the family has to pay room and board.
Thanks for pointing this out! If my mother ends up in the situation of fall-hospital-rehab, I will be alert to this. My mother lives alone, and I will not move in with her, nor she in with me. I will not even stay with her after a release from rehab.
Then when discharge rolls around, the patient's team says "where is the patient going?" and the family's own plan is all in place so all is well, and the patient's family will never have occasion to realise that this was not in fact their job.
You lucked out. Some aren't fortunate to be able to get into a top choice. They sometimes have to settle for a lower rated facility, which not surprisingly usually has many available beds.
Check them out for yourself... as others have said, the hospital gets a referral fee.
Not sure how it works for Medicaid, Medicare but all hospitals still up my knowledge have discharge planners - most are social workers and nurses