Considerations When Making a Referral for Skilled Nursing Care

Patients are transferred from the hospital to a skilled nursing community at lightning speed. Determining the needs for physical, occupational and speech therapy for individuals is based on their tolerance and therapy evaluations. Healthcare professionals should consider the following as they make recommendations for continued care:

• Does the patient live alone, with family or friends?
• Is the family able to meet the mental or physical demands of caring for their loved one at home?
• Does the patient have outside support systems to make the discharge safe?
• Does the patient understand how to take their medications?
• Can the patient explain or describe what medications they currently take?
• Can family or friends understand the patient’s medications or treatments?
• Are there any physical challenges with the patient returning to their prior living setting?
• Are there steps or long distances to critical rooms like the bathroom or bedroom?
• Would the patient benefit from a short-term rehabilitation stay before transitioning home?

Referral Information Needed

Often, hospitals utilize secured portals to facilitate a skilled nursing care referral. A Liberty Health and Rehab staff member will meet with the patient, their family or the patient’s medical professional to conduct a complete evaluation of the patient and coordinate an admission at one of our communities. Our communities coordinate referrals with a variety of medical professionals and are able to accept an admission 24 hours a day, seven days a week. Please provide the following information when making a referral:

• North Carolina FL2
• History and Physical
• PASSAR Number
• Current Medications (Medication Administration Record)
• Discharge Summary
• Current Therapy Notes
• List of Equipment Needs