Memorial Hermann The Woodlands assigns a case manager to each patient who begins assessing post-discharge needs within 24 to 48 hours of admission. For scheduled procedures, the process may begin pre-admission. The case manager reviews clinical needs, identifies an appropriate post-acute level of care, and coordinates with the attending physician and insurer. Families are typically notified of the discharge plan 24 to 48 hours in advance, though involvement earlier in the process leads to better outcomes.

The Woodlands area and surrounding Montgomery County have several skilled nursing facilities in The Woodlands proper, Conroe, Spring, and Tomball. Quality levels vary, and availability for Medicare and Medicare Advantage patients fluctuates. The hospital maintains a referral list, but that list is not exhaustive. A placement specialist can identify facilities with current beds that match the patient’s clinical needs, insurance type, and personal preferences.

The Woodlands and Conroe area have a growing number of assisted living communities with dedicated memory care programs. Options range from larger resort-style communities to smaller residential homes with dementia-trained staff. For patients coming directly from the hospital, the key questions are: Does the community accept residents directly from the hospital? Do they have availability? Can they manage the patient’s current medical needs? A placement specialist can answer these questions quickly across multiple communities simultaneously.

Fall-related admissions often involve hip fracture surgery, and the typical post-acute pathway is skilled nursing facility or inpatient rehabilitation facility (IRF) for physical therapy recovery. If the fall suggests underlying balance, cognition, or home safety concerns, the discharge plan should address those root causes, not just the acute injury. Ask the case manager and attending physician specifically about fall prevention planning as part of the discharge assessment.

Yes. Memorial Hermann The Woodlands has established transfer protocols with Memorial Hermann Texas Medical Center for cases requiring subspecialty care beyond the scope of the community campus. Advanced cardiac intervention, complex neurosurgery, or high-risk procedures may be managed at the TMC campus. Once the acute phase is resolved, patients may return to The Woodlands campus for continued recovery, depending on availability and clinical need.

Medicare Advantage plans require prior authorization for SNF admission before the patient can be admitted. Memorial Hermann The Woodlands case managers initiate this authorization request, but the MA plan controls the decision and the number of days initially approved. Approvals can take 24 to 48 hours; during that window, the patient may remain in the hospital. If the plan denies coverage or approves fewer days than the clinical team recommends, the case manager can assist with the initial appeal.

Yes, if the attending physician determines home discharge is clinically safe. For patients who are functionally able to manage at home with support, direct home discharge with home health services arranged in advance is often the preferred option. Key factors are: Is the home environment safe? Is there a caregiver available? Will home health services begin within 24 hours of discharge? The case manager can facilitate home health referrals, but families should ensure the specifics are confirmed before the discharge date arrives.

Medicaid SNF coverage in Texas applies to facilities with Medicaid-certified beds, and not all SNFs in Montgomery County accept Medicaid — especially Medicaid from day one (as opposed to a Medicare-to-Medicaid transition after the Medicare benefit is exhausted). The social worker at Memorial Hermann The Woodlands can assist with identifying Medicaid-accepting options and, if needed, with completing or updating a Medicaid application. An independent placement specialist familiar with the local Medicaid SNF landscape can expand the list of options being considered.

Bring your family member’s insurance cards (Medicare, Medicare Advantage, or Medicaid), a list of current medications, contact information for the primary care physician, any advance directives (living will, medical power of attorney, DNR), and your own contact information. Having this information readily available speeds the authorization and referral process significantly. Also bring any concerns or preferences about post-acute care — the earlier the case manager knows your priorities, the better the outcome.

Erika knows the Montgomery County senior care market and can act quickly when a discharge date is set. She identifies SNF, assisted living, and memory care options with current availability, arranges tours, and coordinates admissions — often within the same day. Since she is independent of Memorial Hermann and of all care facilities, her advice is based entirely on your family member’s needs. Her services are free to families.