Before a hospital-to-SNF transfer, confirm Medicare eligibility, plan authorization, facility capability, bed availability, and the complete handoff of medications, orders, records, equipment, transportation, and family contacts.
How to compare facilities step by step
- Verify hospital status and coverage. Confirm inpatient dates, Medicare or plan eligibility, prior authorization, network status, and expected patient costs.
- Match the facility to the care plan. Confirm the facility can provide every ordered nursing, rehabilitation, medication, equipment, dietary, and specialty service.
- Complete the clinical handoff. Send the discharge summary, medication list, therapy and nursing orders, allergies, recent results, wound instructions, and follow-up appointments.
- Plan transportation and arrival. Confirm the transfer time, appropriate transportation level, receiving contact, room or unit, and what the patient should bring.
- Set the first care-plan contact. Identify who will update the family, when therapy begins, and how questions or changes in condition will be communicated.
Coverage should be confirmed before the ambulance arrives
Ask the hospital case manager to document the inpatient admission dates and the clinical reason for skilled care. Confirm Medicare certification, Medicare Advantage network status, authorization, bed type, daily copay, and non-covered charges directly with the facility and plan.
The receiving facility needs a complete clinical picture
- Current medication reconciliation, prescriptions, allergies, and last administered doses.
- Discharge summary, diagnoses, recent laboratory and imaging results.
- Nursing, wound-care, rehabilitation, dietary, oxygen, and equipment orders.
- Infection-control status and any required precautions.
- Upcoming specialist visits and transportation needs.
- Advance directive, health-care proxy, and emergency contacts when available.
Know who owns the next decision
Before transfer, identify the hospital case manager, receiving nurse, facility social worker, therapy contact, attending clinician, plan case manager, and family point person. Write down phone numbers and when the first care-plan meeting should occur.
Frequently asked questions
Who confirms Medicare coverage before a SNF transfer?
The hospital discharge team, the receiving facility, and Medicare or the Medicare Advantage plan should each confirm their part. Ask for the authorization and expected patient cost in writing when possible.
What records should go with a patient to skilled nursing?
The handoff should include the discharge summary, medication reconciliation, allergies, orders, recent results, care instructions, equipment needs, follow-up appointments, and emergency contacts.
Can a family choose a different skilled nursing facility?
Patients generally may choose among facilities that can meet the care needs and coverage rules, subject to availability and Medicare Advantage network requirements.