Transitions — Hospital, SNF, and Hospice

Every transition is a point where information gets lost. The patient moves; the knowledge does not follow unless somebody carries it.

When a patient goes to hospital

See Transfer for the assessment and the deadline. For the handover itself:

Send with the patient, or call through:

Current medication list — what they are actually taking, which is often not the list
Baseline function: how they normally transfer, ambulate, and manage at home
Wounds: location, measurements, current treatment
Allergies, code status, and advance directives
Who the caregiver is, and what they can do
Cognitive baseline — this is the one hospitals most often get wrong, and the consequences land back on you

That last point is worth insisting on. A patient with baseline mild dementia who is admitted delirious gets treated as a new cognitive decline, and then discharged to a plan that assumes they can self-manage.

Call the family and tell them we will resume when the patient comes home, and to let us know.

When they come home

The resumption of care is where readmissions are prevented or caused. See Resumption of Care (ROC) — medication reconciliation is the visit.

Transfer to a skilled nursing facility

Usually means our episode ends. Confirm whether the patient is going for short-term rehab with a plan to return home, or permanently — that decides transfer with or without discharge.

Send the same information. A SNF taking a patient at 7pm on a Friday is working from whatever paperwork travelled with them.

Hospice

Recognising the conversation

Hospice is appropriate when the focus shifts from recovery to comfort and the prognosis is six months or less if the illness runs its expected course. Signs it is time to raise it:

Repeated hospitalizations for the same condition, each one taking more out of them
Progressive functional decline despite treatment
Weight loss, declining intake, increasing time in bed
The patient or family asking about "stopping all this"
Treatment burden clearly exceeding benefit
You find yourself thinking you would not be surprised if they died this year

That last one is a legitimate clinical instrument. If you would not be surprised, it is time for the conversation.

Having it

You are often the person who knows the family best. That does not make it your decision, and it does not make it a decision you avoid.

Ask what they understand about where things are heading
Ask what matters most to them now — most people answer with something concrete about home, or pain, or not going back to hospital
Correct the two misconceptions almost everyone holds: hospice is not giving up, and it is not only for the last few days
Explain that hospice adds a team — nursing, aide, social work, chaplain, bereavement support — rather than taking care away
Say clearly that they can change their mind and revoke at any time

Then bring it to the physician and your Field Supervisor. You are opening a conversation, not making a referral alone.

What changes

A patient cannot receive Medicare home health and the Medicare hospice benefit for the same terminal condition at the same time. Election of hospice generally ends our episode for that condition — complete the discharge, and hand over properly.

Handing over to hospice

Call the receiving hospice nurse. Tell them what is not in the chart:

What the patient actually understands about their prognosis
What the family understands, which is often different
Who makes decisions, and who thinks they do
What has worked for symptom control and what has not
The practical things — the difficult stairs, the dog, the son who visits Thursdays

Handing a patient to another clinician

Whether covering a caseload or transferring it permanently, the same rule applies: write down what is not in the chart.

Where the key is, and how to get in
Which door, which entrance, where to park
Anything about the home that matters for safety
What the patient responds to, and what makes them shut down
What you are worried about

The chart carries the clinical record. It does not carry the knowledge that makes the next visit work.