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The Changing Face of Healthcare

The Goal of Hospitalization

Years ago, people stayed in the hospital for days, even weeks until they were strong enough to go home. The question asked each day by the medical staff is, does the patient need to be in an acute care hospital? Times have changed.  The goal of hospitalization today is to treat the patient in the acute setting and safely move them to the next level of care.

This can include:

  • Rehab (subacute rehab or acute rehab depending on functioning and needs)
  • LTACH (long term acute care hospital)
  • Homecare
  • Home with no further services needed


For patients with managed care insurance, including Medicare Advantage policies, there are specific criteria that need to be met in order for patient to be inpatient or observation or else the hospital stay will not be paid for.

Patients with Medicare who enter the hospital will be in 1 of 2 statuses:

Inpatient: this means the individual meets criteria for admission with an anticipated length of stay greater than 2 midnights. (not hours, but midnights)

Observation: the individual has symptoms which warranted further review and testing, but the anticipated length of stay is less than 2 midnights.  This status uses the patient’s outpatient benefits.  There will generally be some sort of financial cost to the patient.

Discharge Planning

Once a patient is deemed medically stable for discharge by their treating physician, a discharge order is then placed.

During the individual’s hospital stay, they will generally meet with a patient care manager who creates the discharge plan and makes any needed referrals.  Depending on the needs of the individual, they may also work with a social worker.  This generally will be when the plan includes a rehab stay or a  transfer to an LTACH.

Many times, there are challenges in creating a safe discharge plan.  This is why discharge planning begins at the time of admission and is a fluid process throughout the hospital stay. The discharge plan can change any time the patient’s symptoms worsen or get better sooner than anticipated.  Therefore the plan changes to accommodate the changing needs of the patient.

The Discharge Planning Team

The patient care managers and social workers work throughout the hospital stay to ensure a safe discharge plan and work with families to this end.

The doctors are focused on the medical stability of the patient.  We can no longer keep patients for an undetermined length of time for social reasons.  To this end, we are working with all of our physician practices to identify and problem solve those patients who may have discharge planning issues. We have embedded care coordinators in most of our primary care practices to work with our high risk patients.  They work in conjunction with the inpatient staff when those patients are hospitalized to create the safest discharge plan possible.

Connections with outpatient providers as well as other community providers is becoming more important than ever.


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