Aftercare after hospital discharge - Isn't this how all hospitals work?

My son's hospital arranged for his admission to a rehab facility. His wife did quite a bit of research and worked with the discharge person. Of course they could only get a place that had openings, but among those they got to pick.

JoAnn, each time one of my parents were in the hospital and needed to go to Rehab, it was the hospital Social Worker who handled finding that open bed.

I am in a large metro area so the Social Work had to jump at the opening as openings were far and few between. Couple times I was able to stall my parent's release and wait for another bed opening to a place closer to home. I couldn't stall too long as the health insurance would not pay for another day in the hospital.

When my Dad was discharged from hospital to rehab this week, we were told to give the social worker our top 3 facility choices. So we ran around looking at places, getting tours and info. There was a clear top choice and we knew when we talked to her two hours after the tour that there was a room. Doing due diligence to identify where we DIDN'T want him was important.

When we first started down the long and twisting journey of parent care, I initially relied on the discharge planner, who was a social worker, to recommend a SNF, as I knew nothing about them. The first SNF wasn't the best choice, we had to work things out, and learned a lot.

From them on I merely asked for a list, then called, made arrangements for a tour and meeting, then told the discharge planner which ones interested me. I'm not sure she appreciated that, but I wasn't going to be limited to her choices, or whatever choices she was advised to use by someone above her in rank.

I have been told a few times that there might not be a bed available, so sometimes it was touch and go, but always a bed opened up so we got in where we wanted from on, except when I made a big mistake and chose a SNF which was "bottom of the barrel" in caliber.

I think who takes the lead on finding a place depends on the experience of the family.

When I was working in the hospital, it was the discharge planner who handled transfers to rehab.

I live in an area that only has maybe 3 rehabs with LT attached. Because of this, I pretty much know the good ones. So lucky. Now DE is a different thing when Mom was in a hospital there for a head wound. Our local hospital doesn't handle heart or head. TG my daughter has worked several rehabs in DE so she knows the good ones. We were able to get Mom where daughter was working. Yes, she got very good care.

Even if the hospital/social worker recommends a NH, do your homework and check them out... happened to us with dad, we'd never had to deal with a NH before and was suddenly in the position of him needing rehab before going home, so we trusted the hospital SW's recommendation and it was a DUMP. Seriously dirty and no one even met with us until the day he was discharged (the NH director was 'very sorry for the oversight'). I guess it was a blessing in disguise, however, even though they only kept him a week before deeming him well enough to go home (though the poor man couldn't walk steps so had to live with me for 10 days). After seeing what we saw and how the place was run, we would have discharged him, anyway. With us and at home he then got wonderful care from visiting nurses and OT/PT therapists.

Check them out for yourself... as others have said, the hospital gets a referral fee.

I believe we had some input as to the place Mom would be going for rehab, but we did not actually make the calls to get her there - the hospital did. I recall being shown a list and being asked what my 1st and 2nd choices were in terms of places to send Mom. Hospital arranged for a bed and I think they arranged transportation to get her there as well. However, I want to be clear that just getting someone to a rehab facility is not the end... it's only the beginning of a journey no one should have to deal with. Your loved one will eventually be discharged from rehab - some people are ready for discharge, but others are not truly ready but get discharged anyway. Mom was discharged prematurely due to her insurance cutting her off and Mom also convinced her therapists that she would be OK in her home with minimal help. I think even after her insurance cut her off, we still self paid for about 10 days (which was a fortune and exhausted a good part of Mom's limited funds). After we brought her home, we discovered how bad she really was. Rehab in a facility is a *carefully-controlled* situation. Granted, it would reveal certain capabilities and deficits the person has, but rehab "success" is a poor indicator of how the person will really do at home. Ask as many questions as you can before bringing your loved one home. And, do your best to describe the person's house to the therapists - particularly fall risks and hazards the person will have at home (which would not be there in rehab).

Ask the rehab facility from the beginning: How well do you work with my loved one's insurance company? Hate to say it, but the insurance game is half the battle. My loved one's attitude and determination declined after she got back to her own home (she was Johnny-on-the-Spot while the facility's rehab people where right there), but I really do believe that her insurance company cut her off too soon and she was sent home too soon. The "home care" she was provided with in her residence was too short in duration and of minimal quality. Minimal. Even at that, Mom was non compliant with the home care people anyway. At least she cooperated wtih the facility's rehab people when they were right there with her and she lived on site. But when her insurance cut her off at the facility, we quickly found it's a fortune to self pay and no one's giving anything away for free these days... You can ask questions like "How much therapy will my loved one get?" and things like that, but it all gets set by the insurance - no matter what you are being told. sad. Oh yes, people will also tell you that you can get 100 days of rehab, but it's not true. Mom got cut WAY before her 100 days and it's all legal. We tried disputing it & I think maybe got a few more days. Do not count on any particular length of time in rehab. We needed to already be planning on what was going to happen next & I'd advise others to do the same. Do not plan on taking a breath while your loved one is in rehab - they can get discharged at any time with little notice if their insurance cuts them and they are unable to pay the bill themselves.

To my knowledge there is usually a discharge planner monitoring the patients care & helping with discharge orders. Often if the person has commercial insurance (non Medicaid, Medicare) the rep that works with that insurance company follows the patient thru hospital stay & again, uses the insurance in network facilities for discharge.
Not sure how it works for Medicaid, Medicare but all hospitals still up my knowledge have discharge planners - most are social workers and nurses