Referral to Admission

Patients are referred from short-term acute care hospitals, emergency rooms, physician offices and Skilled Nursing Facilities (SNF) when a long-term hospitalization is anticipated. Clinical and financial evaluations are conducted prior to a determination. Findings are evaluated based on a patient’s severity of illness, discharge plan, anticipated intensity of services and when there is a reasonable expectation for clinical and functional improvement.

Admission to Hospitalization

Most admissions are scheduled, but emergency admissions do occur. Consent for admission and treatment is required prior to admittance. Patients & family members are encouraged to meet with the case manager to discuss goals, plans, resources and options prior to admission. Within the first 48 hours, the interdisciplinary team will have completed initial evaluations; and, an initial plan of care will be established. We recommend that patient-family conferences be held during the first week to discuss goals, the treatment plan and to work together for an optimal outcome. We also emphasize strong communication between the patient, family members and the case management team to optimize results and assist with the transition.

Hospitalization to Discharge

Each hospitalization starts with a discharge plan to serve as the focal point of care. This facilitates care and treatment. We recognize that these plans often change, so communication among the patient, family members, physicians and our case management team is integral.