BSW uses a standardized care management model across its hospitals, with case managers (typically nurses) coordinating post-discharge needs from the first day of admission. For complex cases, social workers are involved to address financial, psychosocial, and community resource needs. While protocols are consistent across the system, individual case managers vary in their familiarity with local post-acute options, and larger campuses like Baylor University Medical Center in Dallas may have more referral options than smaller community campuses.

BSW case managers recommend post-acute options based on the patient’s clinical needs: SNF for patients needing 24-hour nursing and daily therapy, IRF for patients who can tolerate intensive rehabilitation, home health for patients medically stable enough for home discharge, and hospice for patients in the last phases of a terminal illness. BSW has affiliations with post-acute providers across DFW and Central Texas, but patients and families have the right to choose any Medicare-certified provider.

Baylor Scott & White has rehabilitation services within several of its hospital campuses and has affiliations with IRF and SNF providers across Texas. BSW does not own a large proprietary SNF network, but it maintains referral relationships with numerous post-acute facilities. Case managers may present affiliated providers first. Ask whether any recommended facility has a formal referral or financial relationship with BSW, and whether there are other options not on the standard list.

Baylor University Medical Center (BUMC) in Dallas is the flagship BSW campus, and it has access to some of the strongest post-acute resources in North Texas. Nearby IRF options include Baylor Institute for Rehabilitation (which is part of the BSW system), Post Acute Medical facilities, and Encompass Health locations throughout DFW. SNF options in the Dallas urban core and surrounding suburbs are extensive but vary significantly in quality. A placement specialist can identify the best current options matched to your family member’s clinical needs.

BSW case managers are experienced with Medicare Advantage authorization across all major Texas MA plans. They initiate prior authorization requests for post-acute care and manage the appeals process if authorization is denied or limited. Because BSW is in-network for most major Texas MA plans, authorization is often straightforward — but the number of approved days still varies by plan. Confirm the authorization details with the case manager before agreeing to discharge.

Baylor Scott & White social workers assist patients and families with the non-clinical aspects of discharge planning: financial hardship screening, Medicaid application assistance, advance directive completion, caregiver support, family conflict mediation, and connection to community resources including Area Agencies on Aging. If you are dealing with any of these issues, ask specifically to speak with a social worker — not just the case manager.

Yes. Medicare patients at any BSW hospital can request a review of a discharge decision they believe is premature by contacting Livanta (Texas BFCC-QIO) at 1-888-524-9900 before discharge. Filing an appeal freezes the discharge while Livanta reviews the case. BSW is required to provide a written Important Message from Medicare at least two days before discharge. Non-Medicare patients may also request a care conference with the attending physician, case manager, and hospital patient advocate to discuss discharge timing.

The process is the same in terms of protocol, but the resources available may differ. Smaller BSW community campuses may have fewer post-acute referral relationships and a case manager managing a larger caseload. At community hospitals, it is even more important to advocate for what your family member needs rather than accepting the first recommendation. An independent placement specialist can supplement the community hospital’s referral capacity with a broader market search.

BSW has invested in care transition programs including post-discharge follow-up calls and some telehealth monitoring programs. However, the most effective transition support comes from ensuring the post-acute placement is clinically appropriate from the start. Readmissions are often caused by placement mismatches — sending a patient home when SNF care is needed, or placing them in a SNF without the capabilities to manage their specific conditions. Getting the initial placement right is the most important readmission prevention strategy.

Erika works throughout the DFW and Central Texas markets and knows which SNFs, assisted living communities, and memory care facilities are genuinely strong — beyond what CMS Five-Star ratings reveal. She can expand the placement search beyond the BSW referral list, arrange tours, and coordinate admissions on a tight timeline. Her services are always free to families.