Post-Acute Care: Getting the right care after hospital discharge
Once you leave the hospital, you may need continued support as you recover. Your care team will help determine the kind of post-acute care (PAC) services you need, whether in a skilled nursing facility or rehabilitation center, at home with a home health agency or through other home and community based services.
UW Medicine has a Post-Acute Care Network that includes skilled nursing and rehabilitation, home health, home care, and adult day health services. Our partners have passed a detailed evaluation process, met our service and quality requirements, and are continuously monitored to ensure that all of our patients have a positive experience after they leave the hospital. Patients and families often look to their hospital care team to help them make an informed choice when selecting a care provider after discharge from the hospital. You may choose any facility or agency, whether it is a UW Medicine partner or not, although your options may depend on your insurance coverage, and/or your clinical needs.
Benefits of selecting a UW Medicine PAC Network Partner:
- Aligned goals – Our partners are dedicated to providing better patient care, timely access and patient satisfaction
- Quality & Coordination – Partners have access to UW Medicine electronic medical records and have better coordination with your hospital and physician. Partners meet with UW Medicine hospitals regularly to share best practices, develop clinical guidelines and review quality data.
Skilled nursing facilities and rehabilitation centers support continued recovery through nursing care and therapy provided by registered nurses, certified nursing assistants, physical therapists, occupational therapists and speech therapists. Where the focus in a hospital is to treat and stabilize acute care needs, skilled nursing and rehabilitation aid in your recovery phase by providing wound care, intravenous (IV) therapy, physical therapy and continual monitoring of symptoms and vital signs.
If hospital providers think you or someone you know will benefit from care services at a skilled nursing facility, they will develop a plan for your recovery and provide guidance to the facility to work with you to carry out that plan.
Most stays at skilled nursing facilities are temporary but the duration is different for everyone and determined by such factors as physical condition and support at home.
How skilled nursing facilities differ from hospitals:
- You may share a room with another patient.
- Beds are smaller than those in hospitals.
- Meals often are served in a dining room, though accommodations can be requested.
- Staffing ratios are different: There are fewer registered nurses and more certified nurse assistants, and nurses are responsible for more patients than they would be in a hospital setting. Physicians oversee care plans but will not make rounds to see patients every day.
- Most facilities use off-site pharmacies, laboratories and radiology services.
- There are rooms for socializing, as well as planned activities, for patients to enjoy.
When your hospital provider thinks you are ready for this next care environment, the hospital's social work staff will assist you in selecting a skilled nursing facility. There are many facilities to choose from and numerous considerations to take into account. It's a good idea to visit the facility first and bring a checklist like this one (https://www.medicare.gov/nursinghomecompare/checklist.pdf) to help evaluate the quality of a skilled nursing facility. Medicare and Medicaid beneficiaries may obtain health services from any institution that accepts Medicare and/or Medicaid; however, there may be limitations due to bed availability, specific medical specialty services and your insurance coverage.
Factors to consider include:
- The quality of care and rehabilitation.
- Specialized medical care and staff.
- Private versus shared room.
- Choice of doctor.
- Distance to family or friends to allow for visits.
- Distance to follow-up appointments.
For more information about Skilled Nursing Facilities, visit: https://www.medicare.gov/nursinghomecompare
Patients leaving the hospital are often in a weakened state and it is normal to need assistance with transitioning home. Home Health may be part of an overall care plan or ordered by a physician when certain tasks need to be performed by a licensed medical professional in order for a patient to stay safely at home. These services may include medication management and teaching, disease progression education and medical condition management, wound care and dressing changes, social worker, lab draws, physical therapy, etc.
To qualify for home health, patients must:
- Be homebound (meaning that leaving your home isn’t recommended because of your condition, or it takes a considerable effort to leave your home; you may leave your home for medical treatment or short, infrequent absences for non-medical reasons such as attending religious services, a special event, etc.)
- Have a medically necessary need, which may include intermittent skilled nursing care or therapy (physical therapy, speech therapy, or occupational therapy)
- Be under the care of a physician to determine if patient meets home health criteria
- Have services provided under a plan of care that is established by and periodically reviewed by a patients' physician
For more information about Home Health Agencies, visit: https://www.medicare.gov/homehealthcompare
Home Care is provided by in-home caregivers who assist with non-medical tasks that a patient cannot safely or comfortably do alone. Services may include bathing and personal care, medication reminders, meal planning and preparations, shopping, errands and/or housekeeping.
Adult Day Health
Adult Day Health programs provide caregivers a break while supporting the patient’s well-being and independence. Program participants enjoy educational and recreational programs, limited skilled rehab and nursing therapies, and the opportunity to socialize with peers in a safe, disability-friendly environment.
SKILLED NURSING FACILITIES
HOME HEALTH AGENCIES
HOME CARE AGENCIES
ADULT DAY HEALTH CENTERS
Information above is for King and Snohomish Counties. Please visit partner websites for additional service areas.
The UW Medicine Post-Acute Care Clinical Service is available at many Network partner SNF locations. These UW clinicians will coordinate your care, are available overnight and on weekends for urgent issues, and provide medical care that is tailored to each patient’s needs and condition(s).
- Jenn Azen, MD
- Janice Ingham, ARNP, DNP
- Gina Kim, MD, MPH
- Danna Lei, ARNP
- Isabela Lins Cardim, MD
- Mary Olson, ARNP
- Thuan Ong, MD, MPH
- Gwen Portes, ARNP, DNP
- Jackie Raetz, MD
- Roma Reyes-Cambronero, ARNP, DNP
- Jenny Roraback-Carson, MD
- Ibrahima Touray, ARNP, DNP
- Mengru Wang, MD, MPH
- Sarah White Kimmerle, ARNP
- Monica Zamora, ARNP