By Nikki Tyler, Director of Admissions at St. Ann’s Community
Key Takeaways
- After a hospital stay, many patients need short-term rehab at a skilled nursing facility before going home.
- The hospital social worker coordinates discharge and placement, but the choice of facility belongs to you and your family.
- You’ll usually be asked for your top five facility choices.
- You don’t have to choose a rehab center affiliated with the hospital.
- Each facility decides whether to accept based on clinical needs, bed availability and insurance.
- If the hospital stay is planned, contact your preferred rehab facility ahead of time.
Sometimes a hospital stay is only the first step in your loved one’s recovery. After a fall, fracture, cardiac event or another unexpected medical emergency, many patients are not ready to return home right away. They may need a short-term stay at a skilled nursing facility for rehabilitation or, in more complex cases, long-term care.
For families, the next steps can feel overwhelming. Knowing how the process works before you face these decisions can help reduce stress during an already difficult time.
Who helps arrange rehab after a hospital stay?
The hospital social worker is your first point of contact. They coordinate your loved one’s discharge plan and help arrange placement at a rehab or skilled nursing facility.
Be open about where you would like your loved one to receive care. The decision ultimately belongs to you and your family.
How do you choose a rehab facility after the hospital?
The social worker will typically ask you to name your top five facility choices. Families often consider location, reputation, past experience with a facility and specialized services.
Keep in mind: you are not required to choose a rehabilitation center affiliated with the hospital, unless you prefer to or no other appropriate options are available.
How does the skilled nursing referral process work?
The hospital social worker sends a referral to each facility on your list. Each facility’s admissions team then reviews it and decides whether it can accept the patient.
The referral package includes the patient’s demographic information, insurance and financial details, medical records from the hospital stay, and any documentation required by New York State.
The admissions team considers:
- Whether the facility can meet the patient’s clinical needs
- Current bed availability
- Whether the facility accepts the patient’s payer source, such as Medicare, Medicaid, private pay or long-term care insurance
How can families advocate during the placement process?
Contact the admissions department at your preferred facility to confirm they received the referral. If they haven’t, tell the hospital social worker so the issue can be fixed quickly.
A personal connection with the admissions team also helps. Letting them know you’re interested in their facility and that a referral is on the way keeps communication open throughout the process.
What happens if more than one facility accepts?
When a facility accepts the referral, its admissions team notifies the hospital social worker, who then contacts you. If more than one facility accepts, you can choose the one that best meets your loved one’s needs, and the transfer is arranged for after hospital discharge.
What if your preferred rehab facility can’t accept your loved one?
Ask the hospital social worker why. Common reasons include no available beds, the facility being unable to meet the patient’s medical needs, or insurance limitations.
Not every referral results in an acceptance, and that can be disappointing. Stay engaged, ask questions and make sure you understand the reasons behind each decision. This is an important transition, and your loved one is counting on you to help make informed choices.
Remember that the social worker’s goal is to find the safest and most appropriate care available, based on your loved one’s needs and the options open at that time.
Can you arrange rehab before a planned surgery?
Yes. If your loved one has a scheduled surgery or procedure and will need rehab afterward, contact your preferred facility before the hospital stay.
Pre-planning lets the admissions team prepare for your loved one’s arrival and, when possible, reserve a room in advance. Be sure to tell the hospital social worker you’ve already made arrangements. Planning ahead can simplify discharge and give you and your loved one valuable peace of mind.
Short-term rehab at St. Ann’s Community
The Transitional Care Center at St. Ann’s Community in [Rochester, NY] offers short-term rehabilitation after a hospital stay. To ask about admissions or plan ahead for a scheduled procedure, call [phone number] or visit [link].
St. Ann’s Community: Caring for the Most Important People on Earth™
Frequently Asked Questions
Do I have to choose the rehab facility the hospital recommends?
No. The choice belongs to you and your family. You aren’t required to choose a facility affiliated with the hospital unless you prefer to or no other appropriate options are available.
How many facilities should I list for rehab placement?
Hospital social workers typically ask families for their top five choices.
Why would a skilled nursing facility turn down a referral?
Common reasons are no available beds, being unable to meet the patient’s clinical needs, or not accepting the patient’s insurance or payer source.
Can I reserve a rehab room before surgery?
Often, yes. Contact your preferred facility before a planned procedure so the admissions team can prepare and, when possible, reserve a room.
Does Medicare cover short-term rehab at a skilled nursing facility? (optional, have admissions verify)
Original Medicare Part A can cover skilled nursing rehab after a qualifying inpatient hospital stay of at least three days. Time spent under “observation status” doesn’t count toward that stay. Medicare Advantage plans may have different rules.