Q&A: Postacute care discharge planning resources
Q. What resources should case managers be familiar with when creating a discharge plan for postacute care following a surgical procedure?
A. Many patients admitted for a surgical procedure are evaluated postoperatively by the rehabilitation staff who recommend a discharge disposition and postacute services. If the plan includes a nursing or subacute rehabilitation facility, the patient may visit the facility to reserve a bed and perhaps pay a deposit to ensure placement will be available. CMS’ resource “Your Guide to Choosing a Nursing Home or Other Long-Term Care” reviews insurance coverage, helpful resources, alternatives to nursing homes, and more.
Case managers must be familiar with the resources in their hospital’s geographic location and surrounding areas, such as:
- Subacute and nursing facilities
- Long-term acute care and chronic care hospitals
- Psychiatric hospitals
- Group homes
- Assisted living facilities
- Adult daycare centers
- Home healthcare agencies
- Outpatient dialysis centers
- Outpatient rehabilitation centers
- Outpatient infusion centers
- Homecare aide agencies
- Homeless shelters
- Social service agencies
- Offices on aging
- Veterans Administration hospitals
- Durable medical equipment companies
For more information, see Case Management Patient Communication Toolkit.
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