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Transition Management

Case Management

Post-Hospital Care

When your doctor determines that you no longer need all the specialized services provided in a hospital, but still require medical care, he or she may discharge you to a skilled nursing facility or home health care. The discharge planner at the hospital will help arrange for the services you may need after your discharge. Medicare and supplemental insurance policies have limited coverage for skilled nursing facility care and home health care. Therefore, you should find out which services will or will not be covered and how payment will be made. Consult with your doctor, hospital discharge planner, patient accounts representative and your family in making preparations for care after you leave the hospital. Don’t hesitate to ask questions.

Transition Management

Because UNC Rockingham Health Care wants your discharge process to be a pleasant experience and because we care what happens to you after you leave our hospital, discharge planning must begin at the time of admission. The case management team, which includes nurses, social workers and a chaplain, can help you and your family with arrangements for care following discharge. They can arrange home health equipment such as a hospital bed, commode chair, feeding pump, wheelchair, oxygen, walker, etc. Home Health Care can be arranged if skill needs are identified as paid by Medicare, Medicaid or private insurance carriers.

If placement in a nursing home, rest home, or if assisted living is needed, our social worker will assist in finding an available bed so that you can be discharged to a lower level of care when your physician determines that you are ready.

There are three (3) levels of long-term care: skilled care, intermediate care, and rest home care. The level of care is determined by your medical and physical requirements.

If you require intermediate care, rest home care, or assisted living, you may have to be discharged and await placement at home. However, if you wish to remain in the hospital, you may do so, but you will be responsible for the hospital bill.

Medicare will continue to pay for your care only if you are awaiting skilled nursing placement and only until the first available bed is found.

If patients are receptive to talking with someone about Medicaid, they are referred to Social Services or the eligibility assistance representative.

Financial assistance needs should be addressed by contacting the Business Office or the social worker before or on the day of discharge.

In order to insure that there will be no problems with your discharge plan, we need you to cooperate with the case management team when they contact you or your family regarding discharge plans.

If you have any questions, please tell your doctor or nurse and they will contact the appropriate person to talk with you.

For nursing home and rest home complaints unresolved by your nursing home staff, you have the option to contact the Division of Facility Services.

Nursing home only – 919-733-8499

Rest home only – 919-733-6650

Contact UNC Rockingham Health Care

Phone the hospital at 336-623-9711.