If your loved one is admitted to a specialty care hospital, it’s because their care team wants them to continue their journey to recovery in a supportive inpatient environment. When each person arrives, a case manager is assigned to help them transition to their next level of care, based on how much progress they make during their stay in the specialty hospital.

“Many options are available for the next level of care,” Debra Plummer, District Direct of Case Management, said. “It could be a skilled nursing facility, an inpatient rehabilitation facility or home with home health. It is all dependent on their progress at the point that they’ve maximized the benefit of care in a transitional care hospital.”

Expert Tips You Need to Know Before Leaving the Hospital 600

Plummer oversees all of the case managers in Kindred’s Transitional Care Hospitals, also known as long-term acute care hospitals, in Florida. She says that the most common questions case managers get from patients and families are in reference to insurance and information about the facility they will be transferred to when they’re ready to leave the Transitional Care Hospital.

“Have the discussion with your case manager to clarify insurance benefit limitations to the next level of care, particularly if you have non-standard Medicare policies,” Plummer said. “Benefits differ in each policy, and often that’s what we find to be one of the biggest barriers is when the patient’s insurance doesn’t have home health benefits. It’s an important discussion to have.”

Plummer also advises for the decision makers to tour facility options that their loved one might be transferred to in order to feel comfortable in taking the next step.

When it’s time to leave the hospital, Plummer said the nursing staff reviews both standard instructions and specific precautions that patients should be aware of so their transition is successful. This includes education and information about the illness, a thorough understanding of medications, and a plan for follow-up appointments. Each person’s situation is unique, and the care team can help them identify potential setbacks to avoid.

Specialty hospitals often treat critical or chronic illnesses, and unwanted trips back to the emergency room can be common even when a person has recovered enough to move to a less intense level of care. So common, in fact, that the Centers for Medicare and Medicaid Services have outlined the top three reasons this may happen:

  • Lack of communication among the care team, the person, and their family to identify issues that could become larger problems
  • Poor nutrition or hydration, sometimes unintentionally
  • Medication mistakes that lead to serious side effects

These three scenarios and others can negatively impact a person’s recovery. That’s why it’s important for people to follow through on the advice the case managers and discharge planners provide before the transition.

The key is communication, understanding, education, and awareness. If you have healthcare questions, call 1.866.KINDRED to speak with a Registered Nurse 24 hours a day, 7 days a week. Visit our Kindred Hospitals page to learn more about this valuable level of care.