St. David’s hospitals follow HCA’s standardized case management model, with case managers assigned to inpatients within the first 24 to 48 hours of admission. The process is efficient and protocol-driven. HCA’s scale means St. David’s case managers have access to a broad referral network, and HCA’s preferred post-acute providers may be presented first. Families have the right to choose any Medicare-certified provider — you are not limited to facilities on the hospital’s referral list.

St. David’s case managers can refer to SNFs, IRFs, home health agencies, and hospice providers throughout the Austin metro. St. David’s has referral relationships with a range of local and national post-acute providers. Because St. David’s and Ascension Seton are the two dominant Austin systems, most Austin-area post-acute facilities have admission agreements with both systems, giving families a broad range of options regardless of which hospital system discharged their family member.

Austin has inpatient rehabilitation facility options including Encompass Health Rehabilitation Hospital of Austin (on the St. David’s South Austin campus) and other IRF-affiliated programs across the metro. IRF admission requires meeting Medicare’s clinical criteria, including ability to tolerate intensive therapy. Ask the attending physician and case manager early in the admission whether your family member is a candidate for IRF — earlier referral means a more timely admission if a bed opens up.

St. David’s case managers can identify Austin-area memory care assisted living options when cognitive impairment is a factor in discharge planning. However, the match between a patient’s specific dementia stage, behavioral profile, and a specific memory care community requires more individualized research than most hospital discharge planners can provide under time pressure. A placement specialist can pre-screen Austin memory care communities and identify those best suited to post-hospitalization transition.

HCA maintains preferred post-acute relationships with selected SNFs, home health agencies, and other providers. Case managers may present these options first, and they are often genuinely good options. However, a preferred provider’s availability, specific capabilities, or distance from family caregivers may not make it the best choice for your family member. Ask whether the case manager can provide a full range of options beyond the preferred list, and confirm you have the right to choose freely among Medicare-certified providers.

The North Austin, Cedar Park, and Round Rock corridor has expanded significantly in post-acute care capacity. St. David’s North Austin case managers are familiar with local SNF and assisted living options in that corridor. For families in Leander, Georgetown, or far north Austin, the range of immediately local options may be more limited, but Austin’s overall market breadth makes it feasible to find appropriate placement within a reasonable drive.

St. David’s case managers handle Medicare Advantage prior authorization for post-acute care, consistent with HCA’s system-wide processes. Most major Texas MA plans are in-network at St. David’s. Authorization timelines and coverage limits are plan-controlled. Ask the case manager whether authorization has been received and for how many days before agreeing to a discharge date. Verify whether the recommended post-acute facility is in your MA plan’s network.

If a family member develops a medical emergency at a skilled nursing facility after discharge, the SNF’s nursing staff should assess and stabilize the patient and, if necessary, initiate transfer to the nearest hospital emergency department. For patients with Medicare or Medicare Advantage, returning to a hospital does not automatically restart the hospital benefit period unless a new qualifying condition leads to a new inpatient admission of at least three days. Discuss emergency protocols with any SNF before admission.

Ask the case manager to initiate the home health referral and confirm the start date before the discharge date is finalized. Ensure the agency has received the physician’s orders and that their intake process is complete. Request that home health begins within 24 hours of discharge — ideally on the day of discharge or the following morning. A gap in home health services after discharge is one of the most common preventable causes of readmission.

Erika knows the Austin senior care market and works independently of St. David’s and HCA. She can expand the placement search beyond the hospital’s preferred provider list, identify available SNF, assisted living, and memory care options with the right capabilities, and coordinate admissions quickly when a discharge date is set. Her services are always free to families.