Discharge from the hospital or a rehabilitation stay can be scary, confusing, and overwhelming. Things move fast, and lack of preparation can lead to unsafe outcomes.

Join Elder Care Advocate Laura Daniels, RN, as she provides an essential discharge planning checklist and walks you through every step you need to take for a safe transition home or to a new care setting. Learn how to advocate for yourself or your loved one from day one, what to expect during a hospital stay, and the key questions to ask your medical team regarding medication, follow-up care, and recovery support. Laura emphasizes that the most important care happens after the hospital stay and offers a free Medicare discharge checklist resource to ensure you're prepared.

• Learn the stages of a hospital stay and how to navigate the system.

• Understand the importance of proactive, day-one discharge planning.

• Discover key action items, like coordinating equipment, follow-up appointments, and support services for the crucial first 72 hours at home.

Chapters

00:02 Introduction to Navigating Elder Care with Host Laura Daniels, RN.

00:20 Laura's background as an Elder Care Advocate and founder of Care Advocates.

01:16 Care Advocates' process: Customized care planning and options (assisted living, memory care, in-home care).

02:38 Today's Topic: The overwhelming moment of hospital or rehab discharge.

03:32 Introduction to the Discharge Planning Checklist and key action items.

04:02 Offer for a free, four-page Medicare Discharge Checklist.

04:47 What to Expect During a Hospital Stay: Understanding the process.

05:27 Stage 1: Admission (Emergency Room vs. Planned Admission).

06:36 Stage 2: The Inpatient Phase (Specialists, Vitals, Rounds, Task-Driven Care).

07:44 How to Advocate for Yourself or a Loved One.

08:46 Key Questions to Ask from Day One: Plan, goals, concerns, therapy.

09:14 Taking Ownership of your admission and outcomes (bring a notebook!).

10:04 Asking about medication changes and starting discharge planning on day one.

10:48 Your Rights: Speaking up if you don't feel ready for discharge.

11:29 Questions to ask about the post-discharge plan (rehab, SNF, home health).

12:20 Hospital stay is a temporary stop; focus on what comes next.

13:42 Why Discharge Planning is Crucial: High risk of readmissions and complications.

14:50 The patient/caregiver is a key partner in the discharge process.

15:40 Overview of the Medicare Discharge Checklist components.

16:05 Checklist items: Home assessment, follow-up appointments, transportation.

17:04 Support Services: Home health, meal prep, and community resources.

17:34 Equipment and Medications: Ensuring they are ordered in time.

17:54 Emergency plan and 24-hour contact list.

18:28 The Crucial First 72 Hours post-discharge and need for support.

19:5 6Skilled Nursing Facility (SNF) discharge considerations.

20:25 Resources & Next Steps: CMS checklist, referral service contacts, Medicare helpline.

21:18 Final encouragement and a client story about an unsafe discharge.

22:39 Outro: Contact information and services offered by Care Advocates.

24:07 Free Consultation and contact details: 210-669-2222.

25:06 Closing remarks.

See omnystudio.com/listener for privacy information.

In this episode of Navigating Eldercare, host Laura Daniels welcomes Naeemah Marquez, a Licensed Master Social Worker and the Vice President of Care Transitions for Ignite Medical Resorts. Naeemah shares her expertise on the intricate world of skilled nursing facilities (SNFs) and post-acute care. They discuss the definition of a SNF, the critical role of a case manager as a "broker of resources" and discharge planner, and what families can expect during the admission, stay, and discharge process. Naeemah offers invaluable advice on setting realistic expectations for recovery, coordinating successful transitions, and the importance of family involvement to prevent readmission. She closes with a powerful story illustrating the profound impact of guidance and advocacy in a family's eldercare journey.

• 00:02 Welcome and Introduction to Navigating Eldercare

• 00:20 Host Laura Daniels (Care Advocates Founder) Introduction

• 00:45 The Mission of Care Advocates

• 01:42 Introducing Guest Naeemah Marquez and Her Background in Social Work

• 02:38 Naeemah's Inspiration and Drive in Care Transitions

• 03:07 Defining a Skilled Nursing Facility (SNF)

• 03:34 SNFs as a Bridge to Recovery

• 04:00 The Role of a Case Manager/Discharge Planner in SNF

• 04:39 A Typical Day for a Case Manager

• 05:22 Supporting Patients and Families During the Stay

• 05:54 The Admission Process from the Hospital to Ignite

• 06:41 Average Rehabilitation Stay Length and Determining Factors

• 07:10 Most Common Types of Therapy (PT/OT)

• 07:39 Setting Realistic Goals: The Care Conference Meeting

• 08:08 Advice for Families to Ensure Successful Recovery Post-Discharge

• 09:34 Common Challenges: Patient Acceptance of In-Home Caregivers

• 10:54 Coordinating the Next Steps: Transitioning Home or to Assisted Living

• 11:51 The Interdisciplinary Team (IDT) Process

• 12:21 Key Resources and Referrals Post-Discharge (Skilled Home Health, Hospice, Visiting Physicians)

• 13:49 What Naeemah Wishes Families Understood About Skilled Nursing

• 14:17 Setting Realistic Expectations: Not a 100% Return to Baseline

• 15:14 The Patient Journey from Admission to Discharge

• 16:39 How Ignite Medical Resort is Different (Luxury Rehab and Hospitality)

• 17:39 A Story That Defines Naeemah's "Why" (Sister of a Patient)

• 20:50 Laura's Appreciation for Naeemah's Advocacy

• 21:27 Naeemah's New Role as VP of Care Transitions

• 21:54 Naeemah's Goal for Her Team: Realizing Their Role as Advocates and Change Makers

• 22:50 How to Contact Ignite Medical Resorts

• 23:39 Closing Remarks and Free Consultation Offer from Care Advocates

See omnystudio.com/listener for privacy information.

Join host Laura Daniels, founder of Care Advocates, as she welcomes Roxanne Burgener, a Licensed Nursing Facility Administrator at The Estates at Shavano Park. This episode provides essential guidance on one of the most critical steps in the elder care journey: the transition from hospital to a short-term skilled nursing/rehabilitation facility (SNF).

Roxanne shares her more than 35 years of experience in healthcare, detailing what a skilled nursing facility is, what sets The Estates at Shavano Park apart, and the meaning behind their "No Pass Zone" policy.

What You Will Learn:

• Understanding a SNF: A clear definition of a skilled nursing facility and the difference between short-term rehabilitation and long-term care.

• The Transition Process: A step-by-step walkthrough of what happens when a patient transfers from the hospital to a SNF, and how to ease anxiety during this critical time.

• Key Advice for Families: Top three tips for making the hospital-to-rehab transition smoother, including the importance of bringing familiar comfort items.

• Respite Care: How families can use this valuable short-term stay option to prevent caregiver burnout and who is an ideal candidate.

• Selecting a Facility: Essential questions families should ask and what to look for when touring a skilled nursing facility, focusing on quality of care, cleanliness, safety, and staff interaction.

• The Heart of Care: Roxanne shares a deeply moving personal story that illuminates her passion and calling to work with older adults.

This episode is a vital resource for families and healthcare professionals seeking to make confident, informed decisions about post-hospital recovery and care.

00:00 Introduction to Navigating Eldercare and Host Laura Daniels

01:34 Welcome and Introducing the Topic: Transitioning from Hospital to Short-Term Rehabilitation

01:54 Guest Introduction: Welcoming Roxanne Burgener, Licensed Nursing Facility Administrator

02:10 Defining a Skilled Nursing Facility (SNF)

02:22 Roxanne's Calling: What Inspired Her to Work in Elder Care

04:12 Host Recap: Defining the SNF Setting

04:36 The Estates at Shavano Park: What Makes the Community Unique

05:32 Person-Centered Care and the "No Pass Zone" Policy

07:07 The Transition Process: From Hospital Discharge to SNF Admission

09:39 Advice for Families: How to Make the Transition Smoother and Less Overwhelming

11:47 Understanding Levels of Care: Short-Term Rehab vs. Long-Term Care

14:24 Specialized Services: The Role and Value of Respite Care

16:15 Guidance for Families: Key Questions to Ask When Selecting a SNF

18:38 Final Reassurance for Families Facing the Rehab Transition

19:08 "This is Why I Do What I Do": Roxanne's Inspiring Story

23:14 Conclusion and How to Contact Roxanne Burgener and The Estates at Shavano Park

24:14 Final Thoughts and How to Contact Care Advocates for a Free Consultation

See omnystudio.com/listener for privacy information.