What to expect during the transition from hospital to skilled nursing facility.

Resident talking with a staff member. Your physician and our staff will talk to you about what to expect as you transition from hospital care to a skilled nursing facility.The transition to our skilled nursing facilities actually begins with your discharge from the hospital. Here’s what to expect: Your case manager in the hospital will speak with you about discharge options. Should your care team feel that you qualify for and require additional nursing care and therapy before going home, they will begin the process for the transfer to a SNF (skilled nursing facility).

You should be asked if you have a preference of which nursing facility you’d prefer and at this time, the hospital case manager will begin the referral process. You will be visited by representatives from area facilities, who will go over your medical information, anticipated discharge plan and answer any questions you or your family/friends may have.

Once you have chosen an SNF and a bed offer has been confirmed, the hospital case manager will begin preparing for your discharge. Your hospital case manager will discuss transportation options from the hospital to our center with you. Upon your arrival at our center, you will be settled into your room. You’ll have many visitors during the first 24-48 hours of your stay. These will include:

Nursing staff: An initial assessment will be done to go over your medical needs and to collect your vital signs for your admission paperwork. Our team of LNAs, RNs and LPNs will be around to introduce themselves and familiarize themselves with you and your medical needs.

Social worker: Our social services team will go over the admission paperwork with you and your family. They’ll ask many questions during this meeting, as well as make copies of insurance cards and other important documents.

Therapy team: The therapy team will perform an initial evaluation in order to design a therapy treatment plan for you. This plan will note your prior level of function, barriers to discharge, and your anticipated discharge location.

Activity Staff: Our Activity Director will visit with you to make you aware of the various activities that take place within our centers. While you do not have to attend activities, we encourage attendance at some (or all) as socialization is a key component to wellness.

Dietary: Our dietician will meet with you to go over any dietary restrictions, likes/dislikes, and to ensure proper nutrition during your stay