You have to discharge on a clinical timeline, whether or not housing is ready. When it isn't, the patient is back in 30 days. We secure housing around the discharge so the bed-day stops and the readmission doesn't happen.
Patients released with no stable housing are one of the cleanest 30-day readmission drivers in the data.
Medically-ready SNF patients wait because there's no housing to step down to. Every day is avoidable cost.
Your discharge planner refers the patient as release approaches.
A Care Guide works the timeline so a safe place is secured before the patient leaves — coordinating DME, accessibility, and home-health setup in parallel.
Post-move support keeps the patient housed and out of the ED.
Bring discharge planning and housing onto one timeline.
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