Securing the Right Level of Care After Discharge

Effective Planning Helps Reduce Hospital Readmissions

Transitioning from the hospital back to home is a precarious time for most patients. As hospital case managers know, patients can struggle to understand how to care for their numerous, complex medical conditions. This struggle frequently results in increased readmissions and poor patient outcomes.

For this reason, care planning is crucial to ensure patients fully recover after discharge, and matching the appropriate level of care to your patients’ needs is critical to lowering readmissions.

Determine the Right Level of Care

Multiple factors contribute to choosing and securing a higher level of care, including:

The patient's ability to perform activities of daily living (ADLs), including bathing, dressing, toileting, and preparing meals
The patient's needs for skilled nursing, including wound care, physical therapy, and intravenous medication
Availability of help at home and the ability of caregivers to meet the patient's needs
The patient’s beliefs and wishes, including cultural and spiritual considerations
The patient’s financial situation, including assets and insurance coverage

When evaluating your patient’s need for a higher level of care, check with your state’s Department of Health and Human Services (DHHS) for evaluation requirements.

The Centers for Medicare and Medicaid cover long-term care in cooperation with each state's DHHS for patients with medical and financial need. To demonstrate medical qualification, use the assessment tools provided by your state’s DHHS.

Help at Home

Many patients are fortunate to have family and friends who can help care for them at home. Over 65 million people in the United States care for family members and close friends who are disabled, elderly, or living with chronic illness. In fact, studies show that using family and friends as post-discharge caregivers can significantly improve patient outcomes and reduce readmissions.

While this can seem like an ideal plan, it’s important that caregivers are prepared with the necessary knowledge and skills before they commit to caregiving. Caregivers spend an average of 20 hours a week caregiving, which they frequently balance with full-time jobs, caring for children, and meeting the demands of their daily lives. Without support, family caregivers can experience high levels of burnout or become incapable of caring for their loved one, leading to potentially preventable rehospitalizations.

Family and friends can be an excellent choice for home healthcare, but it is crucial to realistically communicate the patient’s needs prior to this decision and check in with patients and caregivers afterward.

Explore the Options

Beyond home help, many patients and their families are unfamiliar with their options. They may have a vague concept of nursing home care and not much more. Help give your patients a thorough overview of care options that could fit their needs, including:

Long-term acute care. Designed for patients needing acute care for an extended time, generally over 25 days.
Inpatient rehabilitation. Intensive, short-term therapy to improve function.
Transitional care. A step between acute care and a skilled nursing facility.
Skilled nursing. Care for patients with a daily need for skilled nursing services.
Custodial care. Care that includes ADLs but not skilled nursing. This type of care is what many think of as a nursing home.
Home health. Care for patients who need skilled nursing services and are homebound.
Hospice. End-of-life care that is focused on comfort and includes ADLs and skilled nursing.
Assisted living. Community care that provides varying help with ADLs, including meals and transportation, and can include personal care and medication management.
Group homes. An alternative for people with long-term disabilities who require continuous help with ADLs.
Home care agency. Provides caregivers to help with non-skilled ADLs in the home.
Private hire. Caregivers employed directly by the patient. This option can be more economical than going through an agency, but it requires managing employment.

Once an appropriate level of care has been determined, the next step is helping patients understand their options for paying for their care.

Untangle Insurance Coverage

Several types of insurance may pay for long-term care. The yearly cost of a private room in a nursing home providing custodial care is around $100,000 in the United States. Because of this high cost, coverage is often partial and shared between more than one payer.

Medicare and Medicaid. Medicare covers the first 20 days of skilled nursing care and partially covers days 21-100, but does not cover after that. Medicaid covers long-term care for those who meet financial limits.
Private insurance. Depending on the plan, private insurance may help pay for some nursing home costs.
Long-term care insurance. If the patient has long-term care insurance, they can usually qualify for custodial care.
Veterans Affairs (VA) benefits. Senior living is covered through VA benefits.
Life insurance. Patients can surrender certain life insurance policies at cash value to help cover costs.

Nursing homes may be able to bill separately for medical and personal care, so covered medical expenses can be billed to insurance if there is no coverage for personal care.

Use Financial Planning

Millions of Americans have no coverage for long-term care. Medicaid covers most, and sometimes all, nursing home costs and some forms of home care. However, suppose patients have no coverage from other sources, and more income and resources than the Medicaid limits. In that case, they must use personal resources to pay for care until their assets reach Medicaid qualification levels.

Examples of assets include savings, pensions, retirement income, stocks, land, vehicles, and home sale proceeds.

Managing assets can get complex. Patients would benefit from a meeting with a financial adviser specializing in Medicaid planning.

Address Emotional Barriers

Patients are sometimes reluctant to accept care. Their desire to keep living at home may be stronger than the desire to stay well. They may object to caregivers coming into their home for security reasons. It can also be awkward for a patient to get personal care from someone they don't know.

Some ways to overcome these barriers include:

Hold frank discussions about the need for care. A trial period may be an excellent way to start without committing to a significant change or a caregiver.
Facilitate communication between family members about their ability to meet the patient’s needs.
Examine options that the patient is more comfortable with, such as home care versus nursing home care.

To reduce readmissions, supporting your case management team is essential. With strategic care planning, patients can make informed decisions to get the care they need to manage their medical conditions. Better daily management will help them have better outcomes.