Discharge Planning

Jenna Bigham, LSW
Social Services Director
Abbyshire Place Skilled Nursing & Rehab Center

discharge planningIt may be a surprise to some that, upon admission to a skilled nursing facility, discharge planning begins. Some referrals are sent to the facility with the expectation that the individual are either requesting long or short term placement. Those requesting short term placement typically admit for rehabilitation services and in hopes to be discharged back to their previous living arrangements in the community. However, sometimes alternative plans are needed whether that means the person decides to remain a long term resident or to find alternative living arrangements in the community.

The Factors

There are several factors that should be kept in mind when discharge planning. One of these factors is family/community support. For those returning from the community without a support system in place, may find the transition to be difficult. Some individuals require assistance with transferring from bed to wheelchair or from wheelchair to commode to use the restroom. In our area, home health is readily available however, 24 hour a day/seven days a week care is not. Referrals are made once social services is able to assess when the individual and or family along with therapy think a discharge may occur, given the doctor is agreeable and thinks that a discharge is safe and appropriate.

Medicare and Medicaid and most managed plans associated with the two, cover the cost of home health care which includes physical therapy and occupational therapy along with other forms of therapies depending on which agency is chosen. Home health is a great option for those who do not require the strenuous therapy at the facility but who still are not completely back to baseline. The Area Agency on Aging also offers programs to help seniors with independent living in the community. However, like mentioned above, in such a rural area, individuals have to pay out of pocket for 24/7 aid services to help with activities of daily living that are vital to their health.