Medical Social Services in Minnesota

Placement Resources

Several placement resources are available for those who are not ready or are unable to return home following a hospital stay. The social worker will help the patient and family determine what placement resources are available in the community and which are appropriate.

Rehabilitation Hospitals
A rehabilitation hospital is an acute facility which offers intense physical, occupational and speech therapies. Candidates for admission to a rehabilitation hospital must meet certain criteria:

• Progress in therapy while in the hospital, but has not reached maximum goals for rehabilitation
• Medically stable
• Able to participate in a minimum of three hours of therapy daily
• Motivated and cognitively capable of improvement

The physician has to recommend this treatment option. The rehabilitation hospital decides on admission, based on medical information and whether the patient meets the Medicare/insurance criteria for admission.

Assisted Living
Many facilities have assisted living programs. These offer independence in a community setting, along with varying degrees of supervision and services. If this is an option, the social worker can help look into assisted living options in the patient's home area. This option requires payment for lodging and services provided. The price can vary greatly depending on the assistance needed.

Swing Bed
Some hospitals offer swing bed care. A swing bed is an acute care hospital bed that also can be used as a skilled nursing care bed, according to Medicare definitions of skilled nursing criteria. Length of stay is limited to short-term treatment with the goal of returning home.

Transitional Care and Respite Care
Transitional care and respite care are hospital-based programs offering varied levels of care, and daily costs are paid privately. The daily rate depends on how much care is needed. Ancillary services are provided at an additional cost.

Nursing Homes
A nursing home is a public or privately operated establishment where nursing and custodial care are provided if the patient is unable to properly care for himself or herself.

Deciding on Nursing Home Care
Deciding to go to a nursing home can be difficult. The hospital social worker can help by assessing the medical needs at discharge and evaluating how much help is available from family and friends as well as home care options and costs. If going to a nursing home is the decision, the social worker will help locate an appropriate nursing home. When possible, the family should visit prospective homes to help with the decision. Frequently, patients are able to return home after a short rehabilitation stay. Help locating a nursing home is available on the Medicare nursing home compare Web site .

Costs of Nursing Homes
Each facility determines "level of care" (the amount of care needed) from preadmission screening information, including medical diagnosis, doctor's orders and care needs. The social worker helps gather this information and provides it to selected nursing homes for their review. The level of care will determine the cost per day at the nursing home. Resources available to pay for nursing home care are Medicare, private funds, private insurance, long-term care insurance, and Medical Assistance/Medicaid. Guidelines regarding qualification for Medicare and Medical Assistance are very specific. Custodial care is not covered by Medicare.

Preadmission Screening
Many states require that patients be screened before being admitted to a nursing home. Screening is mandatory in Minnesota and, for someone who lives in Olmsted County, the home of Mayo Clinic, the social worker must contact Olmsted County Social Services and provide extensive information. If the patient has a recent history of mental illness or is developmentally delayed, a psychiatric consultation or additional screening may be necessary. Screening is done to confirm that nursing home placement is necessary and to assess the appropriate level of care.

Long-Term Ombudsman Program
The Long-Term Ombudsman program is a patient advocacy program available to help deal with any problems concerning care in a nursing home. Nursing homes are required to provide information on how to contact this agency. The contact number for the Minnesota Long-Term Ombudsman program is (800) 657-3591.