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Admission Process

You can enter a nursing home from home, an assisted living facility, another nursing home or after a hospital stay. The reasons for going to a nursing home are many. Placement may be the result of illness, injury, or the lack of social support. It may be because you can no longer independently perform activities of daily living (bathing, dressing, feeding yourself, moving about, or toileting).

Placement may also be due to a decline in cognitive function, resulting in impairment and breakdown of a person's mental functioning. This may hinder a person's ability to think clearly, or remember well enough to properly care for oneself. Regardless of where you reside prior to admission, an evaluation and a determination of your care needs must be performed prior to admission.

Placement from home

If your loved one can no longer live at home, you can request an evaluation from Adult Evaluation and Review Services (AERS). There is no charge for evaluation services. AERS workers are located in local health departments and consist of a nurse, social worker, and, as needed, a physician, psychiatrist and psychologist. This team will come to the home to perform a comprehensive evaluation that includes medical, environmental and psychosocial assessments. If your loved one has a diagnosis of mental illness or a developmental disability, AERS will perform a preadmission screening (PASRR) to determine if a nursing home is the most appropriate setting.

Call your local health department to request an AERS evaluation. In Baltimore County, the number is 410-887-2754. For other counties or Baltimore City, call the local Maryland Access Point (MAP) Office and ask for the AERS office.

Placement from the hospital

If your loved one is in the hospital and needs continued care after a major illness or injury, the physician may recommend nursing home placement. The hospital discharge planner is responsible for assisting you in locating a nursing home and coordinating all medical information that is needed for the placement.

The physician and any other appropriate staff will work with the discharge planner to provide the nursing home with the information needed to determine the level of care the patient requires. This is essential to make sure the patient receives the appropriate level of care and that it has been pre-authorized by the third-party payer. If the hospital staff thinks the patient is eligible for Medicare skilled care in a nursing home, the discharge planner will arrange for the nursing home to establish a level of care.

If the patient is, or will soon be, on Maryland Medical Assistance and it appears he or she will need a Nursing Facility Services (NFS) level of care, the discharge planner will submit the appropriate paperwork to KePRO for them to establish a level of care. The discharge planner will make the transportation arrangements to the nursing home as well.

Discharge Planner Paperwork
At the time of discharge, the discharge planner is responsible for making sure that the following information is prepared and ready to accompany the patient to the nursing home:

  1. The physician's discharge summary
  2. The discharge summary from nursing, rehabilitation therapists, social workers or others providing care or rehabilitation services
  3. The list of current medications and treatment
  4. The approval form from KePRO, if the patient is on Medical Assistance or has a pending application.