Discharge planning begins at admission at Memorial Hermann TMC — it is a Joint Commission requirement. A case manager will typically make contact within the first 24 hours to assess post-discharge needs. For patients with complex diagnoses, stroke, trauma, or major surgery, the social work team may also be involved early. Do not wait for the hospital to come to you: ask for the case manager’s name and direct contact within the first day of admission.

The most common destinations are skilled nursing facilities (for patients needing 24-hour nursing and daily therapy), inpatient rehabilitation facilities (for patients who can tolerate intensive therapy three or more hours per day), home health services (for patients medically stable enough to go home with professional support), and TIRR Memorial Hermann (the top-ranked rehabilitation hospital in Texas, for stroke, TBI, and spinal cord injury patients).

TIRR Memorial Hermann, located steps from the TMC campus, is one of the nation’s top-ranked rehabilitation hospitals. Referral from Memorial Hermann TMC is handled through the case management team, but TIRR admission is not automatic — their clinical team reviews the patient’s records and determines if the patient meets IRF criteria (ability to tolerate and benefit from at least three hours of intensive therapy per day). Wait times for TIRR beds can be several days. If your family member might qualify, ask the case manager to initiate the referral early.

Medicaid SNF placement in Houston requires finding a facility that both accepts Medicaid and has an available bed — which can be more challenging than Medicare placement. Memorial Hermann case managers can provide a list, but the list may be limited. An independent placement specialist familiar with the Houston Medicaid SNF landscape can often identify options the hospital list misses, including facilities that accept Medicaid from day one rather than requiring a Medicare spend-down period.

Yes. You can request a care conference with the attending physician, case manager, and social worker to discuss the discharge plan in detail. You have the right to ask why a specific level of care was recommended, what alternatives were considered, and what the clinical criteria for that recommendation are. You can also consult an independent senior care placement specialist who can review the plan with you outside the hospital environment.

Memorial Hermann TMC is the primary teaching hospital for UTHealth Houston. This means residents and fellows are often involved in your family member’s care alongside attending physicians. Discharge decisions are ultimately made by the attending physician, who may be a UTHealth faculty member. If you are unclear about who the attending physician is or who to speak with about discharge plans, ask the charge nurse for clarification.

Typically 24 to 48 hours, though this can vary by diagnosis and bed availability pressures. Medicare patients must receive a formal written notice called an Important Message from Medicare at least two days before discharge. If you receive this notice and believe the discharge is premature, you have the right to request a BFCC-QIO review through Livanta (1-888-524-9900) before discharge occurs. Filing before discharge freezes the discharge until the review is complete.

Yes. Memorial Hermann has a home health affiliate and case managers often refer within the Memorial Hermann system. However, you are not required to use Memorial Hermann Home Care — you can choose any Medicare-certified home health agency. If you have a preference, or if a specific agency has provided care for your family member before, tell the case manager on admission so they can work toward that placement.

Yes. Patients coming out of the ICU often have higher care needs, and discharge planning may involve intermediate care options like long-term acute care hospitals (LTACHs), which are designed for medically complex patients who need extended hospitalization-level care but no longer meet acute criteria. Memorial Hermann TMC case managers are experienced with ICU-to-LTACH transitions. Ask specifically whether a LTACH is being considered if your family member had a prolonged ICU stay.

An independent placement specialist like Erika Crossley is not affiliated with Memorial Hermann or any post-acute facility, so her recommendations are based entirely on what is best for your family member. She can review the discharge plan, identify facilities that match the clinical needs and your family’s priorities, arrange same-day tours and admissions, and help you ask the right questions before signing any admission paperwork. Her services are free to families.