UT Southwestern’s case management department handles discharge planning for inpatients at Clements University Hospital and the broader UT Southwestern campus. Given the clinical complexity of many patients, the process often involves interdisciplinary team conferences where physicians from multiple specialties, case managers, social workers, and rehabilitation therapists discuss the discharge plan together. Families are typically included in these conferences — ask to be scheduled for one if you have not been invited within the first few days of admission.

UT Southwestern patients often transition to inpatient rehabilitation facilities (IRFs) for those who can tolerate intensive therapy, long-term acute care hospitals (LTACHs) for those with ongoing acute medical needs, or skilled nursing facilities for those requiring 24-hour nursing in a less acute setting. Home health is appropriate for medically stable patients with adequate caregiver support. For patients with oncology, transplant, or complex neurological diagnoses, the post-acute facility must have specific clinical capabilities to manage ongoing care.

Oncology patients often have specific post-acute needs: IV antibiotic therapy, wound care related to surgical sites, nutritional support, and immune compromise requiring infection-control protocols. Not all SNFs are equipped to manage these needs safely. When evaluating SNF options for an oncology patient, ask specifically about IV therapy capability, infection control protocols, and staff experience with immunocompromised patients. Some SNFs near the Dallas medical district have developed specific oncology-discharge expertise.

Yes. For patients who needed UT Southwestern’s subspecialty resources during the acute phase but whose ongoing care can be managed at a community hospital, a transfer to a hospital closer to home (and closer to family) is sometimes arranged. This is most common for patients from outside the Dallas area who were referred to UT Southwestern. Discuss this option with the case manager and attending physician if distance is a significant factor for your family.

UT Southwestern’s discharge summaries are sent to the primary care physician and any specialists involved in ongoing care. For complex patients, UT Southwestern faculty may schedule follow-up appointments directly. Ask the case manager what follow-up appointments are being scheduled, whether they are at UT Southwestern or with community providers, and how the primary care physician will be kept informed. Gaps in care coordination after discharge are a leading cause of preventable readmissions.

If your family member’s cognitive status has changed during the hospital stay — whether due to surgery, infection, medication effects, or an underlying dementia diagnosis — discharge planning should address both the medical and the cognitive needs. Assisted living with memory care is appropriate when the patient does not require skilled nursing but does need structured cognitive support and supervision. A placement specialist can identify Dallas-area memory care communities that can manage post-hospitalization medical complexity alongside dementia care.

UT Southwestern’s social workers assist Medicaid patients and families with post-acute placement within the Medicaid system. UT Southwestern participates in the Texas Medicaid program, and social workers can assist with Medicaid applications, referrals to Medicaid-accepting SNFs, and coordination with the Texas Health and Human Services Commission for patients who may qualify for HCBS (Home and Community-Based Services) waiver programs for home or community-based care after hospital discharge.

UT Southwestern case managers typically give 24 to 48 hours of notice for planned discharges, though for complex cases this may extend to several days of coordinated planning. Medicare patients receive a written Important Message from Medicare at least two days before discharge. If you believe the discharge timeline is premature, contact Livanta (1-888-524-9900) before discharge to request a review — filing suspends the discharge until Livanta completes its assessment.

UT Southwestern social workers can connect families to Dallas-area community resources including the Dallas Area Agency on Aging, Meals on Wheels of Greater Dallas, the Senior Source, caregiver support programs, and community mental health services. For patients transitioning to home, these resources can supplement formal home health services and provide ongoing support. Ask the social worker specifically what community programs might be relevant for your family member’s situation.

Erika works with families navigating discharge from Dallas’s major medical centers and understands the specialized post-acute needs of complex hospital patients. She can identify Dallas-area SNFs, assisted living, and memory care options with the specific clinical capabilities your family member requires after a UT Southwestern stay — capabilities that go beyond what a standard SNF referral list identifies. Her services are always free to families.