Parkland Health has a large team of case managers and social workers who specialize in discharge planning for the complex population Parkland serves. Given the high proportion of Medicaid and uninsured patients, Parkland’s discharge team is experienced with Medicaid SNF authorization, emergency Medicaid applications, and referrals to county-funded community resources. Proactively contact the case manager within the first 24 hours of admission and clearly communicate your family member’s post-discharge needs and living situation.

Medicaid SNF placement in Dallas County requires finding a facility that both accepts Medicaid and has an available Medicaid-certified bed — which can be challenging, particularly at high-quality facilities. Parkland case managers have knowledge of the Dallas-area Medicaid SNF landscape, but their list may not reflect current availability. An independent placement specialist who works specifically with Medicaid placements can often identify options and available beds that are not on the hospital’s standard referral list.

Parkland Health administers a Charity Care program for eligible Dallas County residents. Post-discharge, uninsured patients may qualify for the Parkland Community Health Plan or for emergency Medicaid if they meet eligibility requirements. The Parkland social work team can screen for financial assistance eligibility and assist with applications during the hospital stay. Initiating this process early is critical — having coverage in place before discharge significantly expands post-acute options.

Parkland Community Health Plan is a Medicaid managed care plan serving Dallas County. Members receive coordinated care through Parkland-affiliated providers. For post-acute care, the plan authorizes SNF and home health coverage for qualifying members. Ask the case manager whether your family member qualifies for Parkland Community Health Plan coverage and whether a specific facility is in the plan’s network before agreeing to placement.

Assisted living is generally not covered by Medicaid or by Parkland’s financial assistance programs — it is considered a residential choice rather than a medical necessity. However, Texas Medicaid’s STAR+PLUS managed care program does cover some assisted living services for enrolled members in participating communities. Ask the Parkland social worker specifically about STAR+PLUS eligibility and participating communities in Dallas County if assisted living is the preferred destination.

Parkland social workers regularly connect patients to Dallas-area community resources including the Dallas Area Agency on Aging, Meals on Wheels of Greater Dallas, the Senior Source, community health centers affiliated with Parkland, and Dallas County mental health services. For patients returning home with limited support, these resources can make the difference between a successful transition and a readmission. Ask the social worker specifically what programs are relevant and get contact information before discharge.

Parkland has geriatric care management resources and care transition programs aimed at reducing readmissions for older adults. The hospital participates in initiatives designed to improve care transitions for high-risk patients, including medication reconciliation, follow-up appointment scheduling, and post-discharge phone outreach. Ask the case manager what specific transition support programs are available for your family member as an older adult patient.

Trauma patients — especially those with orthopedic injuries, traumatic brain injury, or spinal cord injury — often have more complex post-acute needs than medical/surgical patients. Trauma discharge planning typically involves the trauma surgery team, rehabilitation specialists, and sometimes neuropsychology (for TBI patients). If your family member had a significant trauma injury, ask the trauma team directly about the recommended rehabilitation pathway and whether inpatient rehabilitation (IRF or LTACH) is appropriate before accepting a standard SNF referral.

Parkland serves all Dallas County residents regardless of immigration status during the acute care phase. Post-acute care options for undocumented patients are more limited: federal Medicaid programs require citizenship or qualified immigration status, and emergency Medicaid covers only acute emergency care. Parkland social workers are experienced navigating this situation and can identify available community resources, free clinics, and any programs with less restrictive eligibility requirements. This is a sensitive and important conversation to have directly with the social worker.

Erika works with families at all income levels, including those navigating Medicaid and limited financial resources. She knows the Dallas-area Medicaid SNF landscape and which facilities genuinely serve Medicaid patients well. She can work alongside Parkland’s social work team to expand the placement options being considered. Her consultation is always free to families.