Stone Mountain · High-acuity placement
From Hospital Bed to Home in 72 Hours
A fall in a hallway, a urinary tract infection, and a discharge planner's call at 3:40 p.m. on a Friday. This is what the next three days looked like.
The situation
Mr. H. was 84, living alone in Decatur, and had been managing well enough that his daughter — who lives in Charlotte — had not yet toured anywhere. He fell in his hallway on a Tuesday, was found the next morning, and arrived at the hospital dehydrated with a urinary tract infection that had already pushed him into delirium. By Friday he was medically stable, no longer met inpatient criteria, and could not return home alone.
The constraint
The discharge planner offered a skilled nursing facility with a bed available Saturday. His daughter wanted somewhere he could stay if his recovery plateaued, without a second move in ninety days. She called us at 4:15 p.m. Friday with three questions: can you take him, can you take him safely, and what does it cost.
What we did
Friday, 5:00 p.m. — Bedside assessment
An administrator drove to the hospital and completed the assessment at the bedside: two-person transfer, thickened liquids, nine medications including a short antibiotic course, and post-infection confusion expected to clear over one to two weeks.
Friday, 7:30 p.m. — Written plan and price
The family received a written acuity level, a care plan draft, and a firm monthly figure by email — no ranges, no “starting at.”
Saturday morning — Documents
We collected the physician's report, medication reconciliation, and TB screening from the hospital record, and filed the DME order for a hospital bed and transfer aids for Monday delivery.
Saturday afternoon — Pharmacy and home health
Prescriptions transferred to our partner pharmacy with blister-pack scheduling, and a home health referral placed for physical therapy twice weekly.
Sunday, 1:00 p.m. — Move-in
Mr. H. arrived by medical transport. His daughter had already video-toured the room. The caregiver assigned to him met him at the door and stayed with him through the first evening.
The first ninety days
The delirium cleared in eleven days, tracked in our daily log and reported weekly to his daughter. Physical therapy moved him from a two-person transfer to a walker with standby assistance by week six. His antibiotic course finished without a second infection, and his acuity level was reduced at the ninety-day review — which lowered his monthly rate rather than raising it.
He stayed. There was no second move, no skilled-nursing detour, and no re-admission.
What made it possible
A discharge weekend is won on paperwork and relationships: an administrator who can assess at the bedside, a pharmacy that answers on Saturday, and a DME supplier who delivers Monday. Families cannot assemble that in 48 hours. That is the whole point of administrator-managed care.
Details changed with family permission. Back to all family stories.
Facing a discharge date this week?
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