THR uses a care management model consistent across its hospital network, with case managers and social workers collaborating on discharge planning from the first day of admission. THR emphasizes care coordination and continuity, and its case managers typically have strong relationships with post-acute providers in the specific suburban communities they serve. For families, this means local knowledge is generally better at community THR campuses than at large urban systems — but you should still proactively engage and advocate for your specific needs.

THR case managers recommend post-acute care based on clinical needs: skilled nursing facilities for patients requiring daily skilled care and therapy, inpatient rehabilitation facilities for patients who can tolerate intensive rehab, home health for patients stable enough for home discharge with professional support, and hospice for patients in the final stages of a terminal illness. THR has preferred provider relationships, but you have the right to choose any Medicare-certified facility.

Arlington has multiple skilled nursing facilities and assisted living communities, ranging from large purpose-built campuses to smaller residential homes. THR Arlington’s case managers have knowledge of local options, and Arlington’s location in the mid-cities area gives access to facilities in both Dallas and Fort Worth suburbs. For patients who prefer to stay close to family in the mid-cities, the selection is generally good; quality levels vary and availability fluctuates.

Texas Health Presbyterian Dallas is a large flagship campus in North Dallas with access to a strong post-acute market. The North Dallas area has extensive SNF and assisted living options in the Park Cities, North Dallas, Addison, and Plano areas. THR Presbyterian’s case management team is large and experienced, and they typically have strong referral relationships with high-quality area facilities. Families should still exercise their right to choose and consider options beyond the hospital’s referral list.

Texas Health Resources has developed care transition programs aimed at reducing readmissions, including post-discharge phone follow-up, care management for high-risk patients, and in some cases telehealth monitoring. Ask the case manager what transition support programs are available for your family member and which they are being enrolled in. Participation in a care management program after discharge significantly reduces the risk of readmission within 30 days.

Traditional Medicare covers SNF care following a qualifying inpatient stay of at least three consecutive days (observation days do not count). THR case managers can confirm your family member’s inpatient status. For Medicare Advantage patients, THR initiates prior authorization with the MA plan; authorization typically comes back within 24 to 48 hours. Confirm authorization status and the number of approved days before agreeing to discharge.

The HEB area has multiple skilled nursing facilities and assisted living communities in Hurst, Euless, Bedford, and nearby North Richland Hills and Colleyville. The mid-cities market is competitive, and higher-quality facilities sometimes have limited availability. THR HEB’s case managers know the local market well. A placement specialist working in real time can confirm current bed availability across multiple facilities simultaneously.

Yes. If your family member has received a terminal prognosis and curative treatment is no longer the goal, the case manager and physician can initiate a hospice referral. THR hospitals have relationships with multiple hospice providers in DFW. Hospice can often be arranged quickly — sometimes within 24 hours — and can enable discharge home or to an assisted living community with hospice support, which is often the family’s preference for end-of-life care.

THR social workers can connect families to DFW community resources including Area Agencies on Aging, Meals on Wheels, senior center programs, the Senior Source, and caregiver support groups. For patients transitioning to assisted living or memory care, THR social workers may also provide information about Texas long-term care options, though an independent placement specialist can provide more detailed and current market knowledge.

Erika works throughout the DFW suburban market and knows the specific post-acute options near THR campuses in Arlington, Plano, HEB, Allen, Denton, and surrounding communities. She can expand the placement search beyond the hospital’s referral list, identify facilities with specific capabilities, and coordinate admissions on a tight timeline. Her services are always free to families.