Health Systems, Long-Term Care, and Care Coordination
Payer landscape
Medicare Part A covers inpatient hospital, skilled nursing facility (up to 100 days per benefit period, typically requiring a qualifying hospital stay), hospice, and some home health. Part B covers outpatient and durable medical equipment. Part D covers outpatient medications. Medicaid covers long-term custodial nursing home care for those who qualify; Medicare does not. Medicare Advantage and PACE (Programs of All-Inclusive Care for the Elderly) combine and coordinate services, and PACE is designed for nursing-home-eligible adults who wish to remain at home. Know which level of care a patient's need actually matches: custodial care, skilled nursing, home health, or assisted living.
Transitions of care
Medication discrepancies at discharge are a leading cause of readmission and harm. A structured discharge process - medication reconciliation, a written plan, timely follow-up, and a clear responsible party - reduces adverse events. Care coordination includes caregiver assessment, home safety evaluation, transportation, and advance directive documentation. High-risk features predicting readmission include polypharmacy, prior admissions, cognitive impairment, and limited social support.
Long-term care regulation and ethics
Nursing homes operate under federal requirements with standardized assessment; antipsychotics for behavior require documentation of a specific target symptom and nonpharmacologic measures first. Restraints require a medical order and are tightly regulated. Recognize elder mistreatment (physical, emotional, financial, neglect, sexual) and your mandatory reporting duties. Guardianship is a last resort after less restrictive alternatives.
Traps
Assuming Medicare pays for long-term custodial care; missing a medication discrepancy in a discharge summary; failing to ask who will administer medications and provide transportation.
Rule of thumb
At every transition, ask three questions: What changed in the medication list, who is responsible for the next step, and how will we reach the patient?