NAVIGATING THE CARE CONTINUUM

Short-term, intensive medical treatment for illness, injury, or surgery.

• Ask to be present during physician rounds
• Request the case manager on day one
• Know the charge nurse, your escalation point
• You can refuse a discharge plan that feels unsafe
• Every hospital must have a Patient Advocate

Recovery-focused care after a hospital stay through physical, occupational, and speech therapy.

• Request a family care conference in the first week
• Sit in on therapy sessions when permitted
• Track Medicare/insurance days yourself
• Ask about the appeals process if coverage ends early
• Ask what home modifications are needed before discharge

Help with daily activities while maintaining resident independence. Largely private-pay.

• Visit at different times of day before choosing
• Ask what happens if care needs increase
• Attend quarterly care plan meetings with written questions
• Know your state's Long-Term Care Ombudsman
• Build relationships with daily care staff

24-hour skilled nursing care for those with complex ongoing needs.

• Review state inspection reports at Medicare.gov/care-compare
• Request care plan meetings at least quarterly
• Document everything, date, time, who you told
• Contact the Long-Term Care Ombudsman if needed
• Arrange regular visits from multiple people

Comfort-focused end-of-life care. Choosing hospice is not giving up.

• Ask the nurse to explain every medication
• Get the 24-hour on-call number and use it
• Let the chaplain and social worker serve your family
• Plan for what matters most in the remaining time
• Accept volunteer respite care

Specialized care for veterans with its own enrollment and processes.

• Contact a VSO for free benefits navigation
• Keep copies of DD-214 in multiple places
• VA Caregiver Support Line: 1-855-260-3274
• Appeal denied benefits, many denials are reversed
• Ask about VA Community Care if wait times are long