A Medicare-covered stay in a skilled nursing facility (SNF) is often temporary, but the process of discharge can be anything but simple. When a patient is preparing to return home or transition to a different level of care, the discharge plan needs to address not just medical recovery, but also legal, financial, and logistical concerns. Done right, this planning ensures continuity of care, protects assets, and helps families avoid unnecessary setbacks or readmissions.
Many families are surprised by how quickly discharge can happen. That’s why it’s essential to start the process early — often at admission — and prepare for what comes next. From establishing home care services to updating legal documents, the details matter. Without a solid plan, a vulnerable patient may end up back in the hospital or face gaps in care that could have been avoided.
Understanding Medicare Coverage During and After SNF Stay
Medicare provides essential coverage for skilled nursing, but it’s not open-ended. Discharge often occurs when rehabilitation goals are met or medical necessity no longer justifies continued inpatient care. That change can create confusion and financial stress if families aren’t prepared.
It’s important to know when coverage ends and what options exist for continued support. In many cases, Medicare can help cover services at home, but only with advance coordination. Transitional home care, for example, may require prior authorization or must be arranged through a managed long-term care (MLTC) plan. This kind of handoff takes time and precision.
The Danger of the Revolving Door
On a recent episode of Eldercare on the Air, attorney Michael Amoruso warned against the “revolving door” scenario — when someone is discharged too soon or without the right support, only to wind up in the hospital again.
To prevent this cycle, discharge planning must consider the actual home environment and what assistance will be needed day-to-day. It’s not enough to assume someone will bounce back. If they needed help before their SNF stay, they’ll likely still need it after discharge. That means looking realistically at whether stairs, meal prep, or medication routines can be managed safely.
Essential Legal Planning Before Discharge
For families needing financial assistance from Medicaid once their loved one is discharged, legal planning should not be an afterthought. The period before discharge is a crucial window to get protective measures in place, including:
- Medicaid Planning: Align your financial strategy with Medicaid rules to avoid jeopardizing eligibility.
- Medicaid Asset Protection Trusts: Protect the family home and other assets while still qualifying for benefits.
- Power of Attorney: Ensure someone has legal authority to make decisions during and after care transitions.
- An updated Health Care Proxy that gives your agent appropriate authority to manage your health care going forward.,.
Effectively planning ahead and having these documents properly drafted and executed before discharge means fewer delays and smoother coordination with agencies and providers.
Coordinating Home Care with Confidence
A good discharge plan doesn’t stop at paperwork. It ensures continuity of care. If home care is needed, whether short-term or long-term, families should begin interviewing and choosing agencies well before the anticipated discharge date. That allows for scheduling assessments, understanding insurance coverage, and setting expectations. Having a home health aide or visiting nurse ready to meet the patient on Day 1 can make all the difference.
Equally important is making sure the home environment is ready — that a stairlift, ramps, grab bars, or medication systems are installed and working. Often, discharge coordinators and social workers at SNFs can help with these arrangements, but they need families to be transparent and proactive.
Empowered Transitions Require Professional Guidance
Planning for discharge from a Medicare-funded SNF stay is not just about avoiding mistakes. It’s about setting someone up for the best possible outcome. That means engaging with professionals who understand the medical system, the legal tools, and the government benefits available.
At Amoruso & Amoruso LLP, we work closely with families to coordinate estate and Medicaid planning long before discharge — creating peace of mind and improving the odds of a successful transition. Whether your loved one is approaching discharge or just entering a facility, give us a call. The time to act is now.
