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Continuity of Care for Seniors
Plan a Smooth Transition from Hospital to Nursing Home

Providing seniors with the comforts of home

Pre-planning for a patient or family member’s move from a hospital into a skilled nursing facility (nursing home) will make the transition easier for everyone involved.

Helping the patient with worrisome financial arrangements will ease the family’s mind and placate the patient.

You may need to learn or get assistance with Medicare guidelines. For example, a patient must be admitted to a hospital and treated as an inpatient for at least three days before being transferred to a nursing home. Otherwise their initial nursing facility care will not be covered under Medicare.

Medicaid qualifications may vary state to state, but there are general guidelines to know. Eligibility for Medicaid is based on the financial income and assets of the patient. But, people who are not qualified based on their finances may be eligible for Medicaid assistance if they have high medical expenses that “spend down” their income levels. Also, if the patient has a spouse, it’s important to understand spousal protection rules.

With finances secure, you can help a patient have a safe and healthy move by providing all necessary information to the nursing home. It’s unfortunate, but depending upon the facilities involved, you may need to assist with communications between the hospital and nursing home. The most critical information to verify is that the hospital provides accurate and complete medical history and treatment records. If the proper prescriptions are not included with the patient’s transfer, they may not have immediate access to important medications. The continuity of care also includes any ongoing medical treatments that are essential to the patient’s health and comfort, such as dialysis, physical therapy, and pain management.

There is information other than medical records that is vital for a smooth transition. Confirm that the nursing home is aware of cultural needs that will affect the patient’s well-being. Medical transfer records may not include essentials such as language(s) spoken, diet restrictions, and religious practices.

Finally, decorate the patient’s new room with items from home. Family pictures, knick-knacks, and a quilt or linens will make the new surroundings comfortable and familiar.

Many agree that there is a great deal of room for improvement in the patient transition process. It certainly can be overwhelming for family caregivers to handle. If you feel unsure about the process, ask a professional.

Find out more about how Senior Planning Services can help. We provide the assistance needed for a well-planned and stress-free transition for both the patient and their family.





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