If your loved one is in the hospital and needs continued care after a major illness or injury, the physician may recommend nursing home placement.
The hospital discharge planner is responsible for arranging for your loved one to be assessed by the appropriate agency to determine if nursing home care is appropriate and, if it is, to assign the appropriate level of care. If it appears your loved one will be eligible for skilled care under the Medicare program, the evaluation will be done by staff from the nursing homes you are considering. If your loved one is eligible for nursing home care, the hospital discharge planner may offer assistance in finding a suitable vacancy. He or she will also make sure that the following information is provided to the nursing home by the hospital staff at the time of transfer:
• The level of care determination from KePRO, if it is needed • The physician’s discharge summary • Other discharge summaries as needed (for example, from nursing, rehabilitation therapists, social workers, etc.) • A list of current medications and treatments prescribed by the physician
The discharge planner will make the transportation arrangements to the nursing home as well.