University Health has a dedicated case management and social work team that begins discharge planning within 24 to 48 hours of admission. Given the complexity and social vulnerability of much of the patient population, social workers play a particularly prominent role — not just in logistics but in connecting patients to the full range of county, state, and community resources. Families should identify themselves to the case manager early and communicate any known barriers to a safe discharge: no caregiver at home, housing instability, limited transportation, or pending Medicaid applications.

University Health social workers have extensive experience with Medicaid SNF placement in Bexar County. San Antonio has a large number of Medicaid-accepting SNFs, though quality and available beds vary. University Health may also be able to refer to SNF-level care within county-funded programs for eligible patients. An independent placement specialist who works specifically in the San Antonio Medicaid market can supplement the hospital’s referral list with current bed availability information.

For uninsured patients, University Health social workers can assess eligibility for emergency Medicaid, the CareLink financial assistance program (Bexar County’s medical assistance program), and referrals to community health centers affiliated with University Health for follow-up care. Post-acute SNF placement for uninsured patients is extremely limited — Medicaid coverage is typically required for SNF admission. Early initiation of Medicaid or CareLink applications during the hospital stay is critical to expanding post-acute options.

CareLink is Bexar County’s medical assistance program, administered by University Health. It provides financial assistance for care at University Health facilities for income-qualified Bexar County residents. CareLink coverage applies primarily to University Health services, not to private SNFs or assisted living communities. For patients transitioning to post-acute care outside University Health, traditional Medicaid or private insurance is typically required. Ask the social worker about CareLink eligibility and its applicability to your family member’s post-discharge needs.

University Health’s Level I Trauma designation means it receives and manages the most severe injuries in Bexar County. Rehabilitation services, including physical, occupational, and speech therapy, are integrated into the care of trauma patients. For patients who need intensive post-acute rehabilitation, University Health case managers can facilitate IRF referrals to Encompass Health, Methodist Healthcare Rehabilitation, or other San Antonio IRF providers. If your family member had a significant traumatic injury, ask specifically about the recommended rehabilitation pathway.

University Hospital is the teaching hospital for UT Health San Antonio, and subspecialty care is managed by UT Health faculty physicians. Discharge planning for academically managed complex cases involves the attending physician (often a UT Health faculty member), case management, and relevant subspecialty teams. Families should know who the attending physician is and ensure that discharge planning conferences include that physician’s input on the recommended post-acute trajectory.

University Health serves a predominantly Spanish-speaking population, and the hospital has extensive Spanish language resources including bilingual case managers, social workers, and patient navigators. Post-discharge placement in bilingual SNFs and assisted living communities is a standard consideration for Spanish-speaking patients. San Antonio’s senior care market is the most linguistically accessible in Texas for Spanish-speaking patients.

If no appropriate SNF bed is available, University Health may continue the patient’s hospital stay until placement is secured, but they may also issue formal notice that the patient no longer meets acute inpatient criteria — at which point the family may become responsible for daily charges. The case management and social work team should be working on placement options in parallel with the clinical care. If you are concerned about the pace of placement efforts, ask the case manager directly what options are being pursued and the expected timeline.

University Health social workers can connect patients to the San Antonio Area Agency on Aging (AAACSA), Bexar County Adult Protective Services for vulnerable adults, Catholic Charities of San Antonio, Meals on Wheels San Antonio, and various other community programs. For patients returning home with limited support, these resources are critical bridge services that can prevent readmission. Ask the social worker to conduct a comprehensive community resource assessment before discharge.

Erika works with San Antonio families at all income levels and all insurance situations, including those navigating Medicaid and limited financial resources. She knows the Bexar County senior care market — which SNFs and assisted living communities accept Medicaid, which have bilingual staff, and which have current availability. She can work alongside the University Health social work team to expand the options being considered. Her consultation is always free.