Yes. Both Ben Taub and LBJ have case managers and social workers who handle discharge planning. However, caseloads at public safety-net hospitals are typically higher than at private systems, which means less individual attention per patient. Be proactive: ask for the case manager’s name within the first day of admission, and do not assume they will reach out to you. If you have concerns about discharge safety, ask specifically to speak with a social worker, not just a case manager.

Harris Health patients are predominantly Medicaid-eligible, and the system has established referral relationships with SNFs that accept Medicaid. However, Medicaid SNF beds in Harris County are limited, and wait times can extend the hospital stay. Harris Health also operates its own Long Term Care services, including a skilled nursing unit at Quentin Mease Community Hospital, which may be available for qualifying patients. An independent placement specialist familiar with the Houston Medicaid SNF landscape can identify additional options.

The Harris Health Financial Assistance program (historically called the Gold Card) provides discounted or free care at Harris Health facilities for income-qualified Harris County residents. Gold Card coverage applies to Harris Health facilities and contracted providers — it does not automatically cover care at private SNFs or assisted living facilities. When planning post-acute care for a Gold Card patient, ask the social worker which post-discharge services are covered under the program and which would require private payment or Medicaid coverage.

Yes, but this is unusual and typically requires a clinical reason for transfer, not simply a preference for a different hospital. More commonly, patients are discharged from Harris Health and then placed at a post-acute facility of their choice. If a patient requires a level of subspecialty care not available at Harris Health, transfer to a specialty center like the Texas Medical Center may be arranged — but this is a clinical decision, not a patient right.

Harris Health social workers can connect patients with community resources including adult protective services, homeless shelter programs, and county-funded case management. For patients who need ongoing placement and have limited support, the Harris Center for Mental Health and IDD and various Area Agency on Aging programs may provide coordination. If a family member lacks a safe discharge destination, make this known to the social worker on admission — not on the day of discharge.

Uninsured patients at Harris Health are assessed for financial assistance eligibility. Post-acute care options for uninsured patients are more limited — private SNFs typically require Medicare, Medicaid, or private insurance for admission. Uninsured patients who need skilled nursing care may be referred to Harris Health’s own long-term care program, or a social worker may assist with emergency Medicaid application if the patient qualifies. An application for Medicaid should be initiated as early as possible during the hospital stay.

Memory care is typically offered in assisted living facilities with dedicated dementia units, not in skilled nursing facilities (SNFs). If your family member has a dementia diagnosis and you believe memory care is more appropriate than an SNF, discuss this with the social worker. Transitioning from an acute hospital directly to memory care assisted living is possible, especially if the patient is medically stable and does not require skilled nursing services. A placement specialist can help identify memory care communities that have current availability and match the level of care needed.

Yes. Harris Health has a Patient Relations department at each hospital. You can ask to speak with a patient advocate if you have concerns about the discharge plan, feel pressured to make a decision, or believe your family member’s rights are not being respected. You can also contact the Texas Health and Human Services Commission if you believe a patient’s rights under Medicaid are being violated.

For patients with straightforward post-acute needs and Medicaid or Medicare coverage, discharge planning may be completed in two to three days. For patients with complex medical needs, limited insurance coverage, or social challenges (no caregiver, unsafe home environment), the process can take significantly longer. Discharge is sometimes delayed not by medical factors but by placement availability — particularly for Medicaid SNF beds. Families can shorten this delay by engaging early and having a placement specialist working the options in parallel.

Erika works with families at all income levels and all insurance situations, including Medicaid and uninsured patients. She knows which Houston-area SNFs and assisted living communities accept Medicaid, which have availability, and which have the specific capabilities (dementia care, bilingual staff, specific therapies) your family member needs. She can work alongside the Harris Health social work team to expand the options being considered. Her services cost the family nothing.