Q: How can I ensure my loved one has a safe discharge plan after a hospitalization?
A: Following a stay in a hospital, effective discharge planning is essential to ensure that your loved one receives the care they need as they transition from the hospital to your home or another facility.
Medicare requires that hospitals screen inpatients and provide them with a discharge plan, in writing, before they leave the hospital. The plan will assess and identify what your loved one’s needs will be once they leave the hospital and arrange for the appropriate care. The discharge plan will typically involve not only the patient, but family members, anyone who has been designated as Health Care Proxy, and doctors and members of hospital staff.
While the hospital’s main goal should be to return your loved one back home, it may be necessary for them to be moved to a skilled nursing facility. Skilled nursing facilities are residential centers that provide nursing and rehabilitative services to patients on a short-term or long-term basis. Skilled nursing care is a high level of care that can only be provided by trained and licensed professionals, such as registered nurses (RNs), licensed professional nurses (LPNs), medical directors, and physical, occupational, and speech therapists. Examples of the services provided at a skilled nursing facility include wound care, medication administration, physical and occupational therapy, and pulmonary rehabilitation. Generally, patients who are admitted to skilled nursing facilities are recovering from surgery, injury, or acute illness, but a skilled nursing environment may also be appropriate for individuals suffering from chronic conditions that require constant medical supervision.
Part of a successful discharge plan will be to review which post-discharge services will be covered (or not covered) by your loved one’s insurance (e.g. Medicare) and what out-of-pocket expenses can be expected. If you or a loved one is interested in using Medicare to cover skilled nursing care, there are specific admission requirements set by the federal government:
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The individual has a qualifying hospital stay. This generally means at least three in-patient days in a hospital.
The doctor has recommended skilled nursing care for the individual on a daily basis. The care must be provided by skilled nurses and therapists or under their supervision and should be related to the condition that was attended to during the qualifying hospital stay.
The individual is admitted to a skilled nursing facility that is certified by Medicare. A skilled nursing facility must meet strict criteria to maintain its Medicare certification.
Usually, the skilled nursing care services covered by Medicare include the room charges, provided that it is a semi-private or shared room, meals at the facility, and any nutritional counseling, as well as costs of medication, medical supplies, medical social services, and ambulance transportation. It also covers rehabilitative services that are required to recover from the condition, such as physical therapy, respiratory therapy, and speech therapy.
Hospital staff are required to educate and train you and any caregivers about your loved one’s needs by providing a clear list of instructions for their care and information about medications and referrals for future care. Equipping yourself with this information can help ensure that your loved one is discharged as safely and cost-effectively as possible.
Brittni Sullivan, Esq. and Dylan Stevens, Esq. are attorneys at Burner Law Group, P.C. focusing their practice areas on Estate Planning and Elder Law. Burner Law Group P.C. serves clients from Manhattan to the east end of Long Island with offices located in East Setauket, Westhampton Beach, New York City and East Hampton.