The Pelham Podcast

From Hospital to Home: Navigating Post-Acute Care

• SRHS Podcasts • Season 1 • Episode 4

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The hospital isn’t the finish line—recovery is. We unpack how post-acute care actually works, from intensive inpatient rehab and skilled nursing to home health, palliative care, and hospice, and we explain how case managers remove friction so families don’t feel lost at discharge. You’ll hear how different care levels fit together, why insurers require certain criteria like the Medicare three-midnight rule, and what “observation” really means for coverage.

We also clear up one of the toughest myths: assisted living is typically private-pay. While insurance can cover services delivered there—like home health or hospice—it usually won’t cover room and board. Knowing this early helps families plan without panic. You’ll learn when acute rehab is the right call, why long-term acute care hospitals serve medically complex patients, and how home health nurses and therapists spot risks inside the home that hospitals can’t see.

Our favorite part is the human side: case managers as steady guides, palliative care aligning treatments with what matters most, and hospice maximizing the time and comfort people have—never “giving up,” always focused on living better. Thanks to shared electronic records across our system, every provider sees the same medication list, therapy notes, and progress, which cuts duplication and speeds safer handoffs. And if you need help right now, one number—864-560-CARE—connects you with a nurse who can steer you to the right service.

If this conversation helped you understand the journey from hospital to home, follow the show, share it with someone who needs clarity, and leave a review with the question you still want answered. Your feedback shapes future episodes.

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Welcome And Guest Introductions

SPEAKER_00

You're listening to the Pelham Podcast with Tony Kay, the show that highlights all things Pelham Medical Center. Thank you for listening. For more information, visit Pelham MedicalCenter.com.

SPEAKER_02

Well, welcome everybody to another edition of the Pelham Podcast. Uh, joined uh today by two ladies from Spartanburg Regional Healthcare Systems Post-Acute Division. Uh post-acute care services are in general things outside of the acute care hospital. So if you have somebody go to a rehab facility or a nursing home, home care, those are services that in healthcare parlance are called post-acute. And Leanne Thompson is a system director within our post-acute care services and has responsibility for case management. And Carla Lambs, the chief nursing officer of our post-acute care division. Ladies, welcome.

SPEAKER_03

Hey, thanks for having us.

SPEAKER_02

Well, very glad y'all are here. I I think you know these uh um stories or discussion topics can really hopefully helpful for the audience because I think people naturally assume most health care is a doctor's office or a hospital, and there's so much to the industry that uh might not be known until you need it. So this will be, I think, a very informative discussion. But uh Leanne, why don't you uh tell our audience a little bit about yourself, your background, and how you got to the role you're in now?

SPEAKER_03

Absolutely. So I this past year I've celebrated my 28th year with the system. So my entire adult life, I have worked in case management through Smartwork Regional Healthcare System. I started off as a floor orthopedic case manager, uh, spent about five years at the Church Street campus, and then I transitioned over to PostAcute where I spent about 20 years. And recently, I guess the last year and a half, I took the role of the system director of case management for the system.

SPEAKER_02

All right.

Defining Post-Acute Care

SPEAKER_03

So that includes all campuses, including PostEcute.

SPEAKER_02

And you grew up in Spartanburg?

SPEAKER_03

I did not. I actually grew up in Cherokee County. Um, social work was not, I was probably the your non-traditional student, or maybe it's more traditional. I had no clue what I wanted to do as an 18-year-old at the College Charleston. And then so I bounced around a couple ideas and I did an internship, a social work internship at Spartanburg Regional 29 years ago. And I've really never left since. Um, I think it was a natural fit for me being a social worker. As uh my mother would always say, I was really nosy. Um, so I love hearing people's stories. How can you help somebody? Um, so it was a great fit for me.

SPEAKER_02

Cool, cool, great. Well, and I think that you know, case management's another function while it's in the acute care hospital is probably something that most people don't think about either. So we'll get to dive into that a little bit. Carla, what about you? Give us a little bit of your history um in the upstate and with Spartanburg Regional.

SPEAKER_04

So I am from Spartanburg County and grew up in this area. I originally started my career um nursing by trade, graduated from USC Um upstate. Was upstate, it was Spartanburg then, USC Spartanburg. Um graduated from there, began um my nursing career at Mary Black Hospital, actually, um, and learned a lot about nursing. Um, I had a role as a nurse manager, charge nurse. I that's the flexibility in nursing, just done all kinds of things, and then joined a team that was brand new at the time was case management. And so um that's where I originally got my training. Leanne and I met about 20 years ago. Um she convinced me to come to uh Spartanburg Hospital for Restorative Care over to the Post Acute space. Um, and so I did that. Um, really enjoyed uh learning a lot about our healthcare system, working with the various campuses, working uh in post-acute, learning that industry. And then um the opportunity came available in 2019, and I accepted the chief nursing officer role uh for uh the Postacute division, which is really exciting. Uh so my career started in nursing, dipped into case management, back to clinical nursing, um, where I get to use both sides of my hat now. So I'm enjoying that. That's great.

SPEAKER_02

And y'all have worked together a long time, so you've got some dirt on each other. We won't we won't explore that in today's session. That'd be good.

SPEAKER_03

That's for a later session for sure.

SPEAKER_02

Well, we definitely got some experts here that uh I think our audience will ultimately value y'all's perspective on uh how you're part of the healthcare system and industry works. So um why don't you uh one of y'all take a stab at uh maybe defining what post-acute care services is? How is how is it different than what people might think of a traditional hospital? Because there's really a lot to it.

SPEAKER_04

Yes. You want me? I'll take

Skilled Nursing And Home Health Basics

SPEAKER_04

that one. So for post-acute services for our health care system, we have a long-term acute care hospital that's Spartanburg Hospital for Restorative Care. Um, we have three skilled nursing facilities. Um, one is a short-term skilled, it's in Spartanburg Hospital for Restorative Care. And we have two residentials, which would be Ellen Sager and Woodruff Manor. Um, and they can also accept skilled residents. We have home health services, which serves four counties for the upstate. Um, we have hospice, which does the same, and we have a hospice house, um, and we have an acute rehab and post-acute services best described, I think, is that we are the partner with the acute care hospitals to be able to help people get back to their best um life, their help them meet their goals, whether it return home or if they need some short-term rehab before they go home. We want to come alongside them and do that. Um, in our systems, post-acute division, we have the benefit of really being able to work with the healthcare system. We have the same uh physician practices, the medical group of the Carolinas. So we have the same health care records. Um, and that makes it really nice for us to come alongside um our healthcare system and physician practices to serve our community in that way.

SPEAKER_02

And explain for the audience a little bit about you use the word skilled nursing, you know, versus uh other kinds of services within Postacute. We uh explain to everybody what that means.

SPEAKER_04

So, skilled services, so if we're talking about skilled nursing facility, sometimes folks need to go into a skilled nursing facility for the focus of just skilled rehab, and then they may not be able to go home and they're gonna become residential at that point. Um, we have two skilled facilities that we can do that in. Um, and home health, skilled, skilled by the term for home health is really we need that nurse or physical therapist to come out and come alongside those patients to make sure that they um have every opportunity to return to optimal health and they require the skill of a registered nurse or a therapist or a CNA to come alongside to help them retrain, regain, that kind of thing. Um skilled, we use skilled terms in post-acute all over about like the acute care hospital uses the word inpatient and observation. Um and so for post-acute, we want to make sure that we have folks that have a skilled need. Um and so that's I probably use like a nurse or a therapist. Yes, like a nurse or a therapist, yes. Okay.

SPEAKER_02

Yeah, and I I think um, you know, so you've got what we call the acute care hospital, which is if you go to the hospital, that's what people normally would traditionally think of, and by acute, we're trying to treat uh current situation and uh take care of people and then get them either home or to the next level. So um you brought up uh um acute rehab. Talk a little bit about what you might do in there. Obviously, people are getting rehab services, but what what do you do in an acute care or acute rehab facility?

SPEAKER_03

We use the term you'll hear rehab used a lot that could cover several different spaces. As you talked about, the skilled level of care is rehab, but we also have an acute rehab.

Acute Rehab And LTAC Explained

SPEAKER_03

And for those patients that need a little more intensive therapy, so for an acute rehab, um, under the guidelines, you have certain diagnoses, but you also need to be able to tolerate three hours worth of therapy a day. Um, so it you work with your case manager and your physician, and therapy is a huge part of the care team that helps you decide which is the most appropriate level of rehab that you need. But an acute rehab is really set up and they do a phenomenal job if you've had a stroke or an amputation or a hip fracture, uh, and you can tolerate that therapy and need the physician intervention.

SPEAKER_02

Okay. And you also mentioned the word long-term acute care hospital or LTAC, and that's another component of our industry. And maybe tell everybody a little bit about what an LTAC does.

SPEAKER_04

So a long-term acute care hospital uh really takes the sickest of the sick um patient from the acute care hospital. We receive about 70% of all of our admissions from a critical care unit or what um the acute care hospitals call an intermediate or step-down unit. Those patients are very complex. Our average length of stay is about 25 days, and they require usually we accept patients who are acute respiratory failure or who are on the ventilator, requiring long-term IV antibiotics, really complex wounds. That's our favorite type of patient. That industry, the long-term acute care hospital, has been able to show really evidence-based how that industry is valuable. So we accept those from all over.

SPEAKER_02

Okay. Yeah, that and that really uh sort of is helpful because what we're trying to do here is inform people. And so for the listening audience, uh, what y'all have heard is you know, we've got different components of service locations within the healthcare industry. Spartanburg Regional Healthcare System has these resources because if we didn't, our our acute care hospitals would just stay jam-packed full with people who, in many cases, didn't need to be there. And uh the health care industry has created these other entities that are what I guess for lack of a better term, more capable or better capable of taking care for those specific needs to free up the acute care hospital, which is designed for short stay and shorter stay patients, and people can get care that they need in different cycles in different locations. And so I think that that's hopefully for you guys listening, very helpful in understanding uh why healthcare is set up this way. Every one of these different locations has a different cost structure to it, as well as the resource requirements, and that's really why it's set up the way it is. So I think that's very helpful. Thank y'all. You know, at a high level, we've talked through a little bit about uh just the various components of um the healthcare industry, and and by and large, um you know, I think it's fair for our audience to know that you know Medicare uh drives a number of things, and some of these services get created because the the government is looking for ways to find lower cost locations for services. I'm not saying that quality isn't imperative in the government's mind, and and and in fact, oftentimes these people do get better care because that that's what their focus is at these locations. But the the chief driver oftentimes has been, you know, payment schema so that uh you know we can get people out of the hospital. So understanding uh that, talk talk to us a little bit, because I think people use the word putting mom or dad in an assisted living. Uh Leanne, talk to us a little bit about what assisted living is and is that something that would be traditionally covered by insurance?

SPEAKER_03

Absolutely, I'd be glad to. So assisted living is basically like it says, that it's a place that you can go to stay and live where you're get a little bit of assistance. They can help with meals or bathing or medications. It's a really a great place where mom or dad or

Why The System Is Built This Way

SPEAKER_03

yourself's not doing well at home and you're having need some help, but you're able to do some things. An assisted living is a great option because you have that 24-hour support at that facility. However, one of the barriers that we see for assisted living is payment. Unfortunately, uh insurance companies of any sort, Medicare, Medicare Advantage private, it do not cover assisted livings. So it is the responsibility of the patient and family.

SPEAKER_02

Okay. Okay. And that that's helpful because that that word you know gets said a lot, and I don't know that everybody fully understands that that comes out of someone's pocket directly.

SPEAKER_03

Now there are some a little, I mean, give up on the assisted livens. If you go to an assisted living and you need additional support that they allow, like home health services, hospice services, outpatient therapy that they may have in their facility, now that is covered under your insurance. It's just basically the room and the board of the assisted living. So if you need specialty services, your insurance traditionally covers those. So it's in conjunction with that.

SPEAKER_02

But if you put somebody in a in a skilled nursing facility, that's generally going to be an insurance-driven.

SPEAKER_03

It is, as long as you have the skilled need, absolutely.

SPEAKER_02

All right. So and do do understand that, because that's pretty critical the way these things are set up. You know, both of y'all have a background in case management, so it might be helpful as as we start to sort of unfold what post-acute care does and how it's important within our system, maybe telling everybody a little bit about what case management does, and then what are some of the requirements about getting somebody from a hospital to a nursing home or an acute rehab or an LTAC? What are some of the things that y'all experience in trying to get people from a hospital to the next place of care?

SPEAKER_03

I'll give Pelham as an example. So case management, here we have there, our case managers are located on each floor in each area. So on admission, uh based off referral, when I say referral, we use that term extremely loosely. Anybody can make a consult or referral to case management. The therapist, the physician, families can always request a case manager to see them. And our biggest function here at Pelham and other acute care hospitals is really helping patients and families transition to what's next when they leave here. Majority of our patients go home and need nothing from us, have no service needs. But we see a lot of folks that need something once they leave here. So the case manager meets, does an assessment with the patient and family, and they work together with their care team, physician, nursing, therapist to determine what their location, what their post-acute need is going to be when they leave here. And based on kind of where they are, what their needs are, then they go from there. Let's give the example a skilled nursing facility. It's determined that you're gonna need your loved ones gonna need to go to a short-term nursing home for rehab once they leave here. What does that look like? Um it, you know, and it varies sometimes on your payer. Let's say, for example, if you're a traditional Medicare patient, you have to have something called a three-night qualifying stay. And that has to be an inpatient stay. So I know that's something we work with a good bit. Um, we have to have conversations, sometimes harder conversations with families because there's um different types of statuses when you come in based on your medical need. If you come in and

Assisted Living And Who Pays

SPEAKER_03

you're in an observation status, which means, you know, you're here to be here for us to observe you, uh, but you don't meet the criteria to be inpatient. We're expecting your stay to be your medical needs to be met in less than two midnights, then Medicare does not recognize that as a qualifying stay. Now, if you come in and you're inpatient after that third night, you qualify for Medicare coverage as long as you have the skilled need. We do have some examples of a Medicare advantages that don't always follow that same rule with Medicare and do allow folks to go at some point in observation to skilled nursing facilities. Same thing with inpatient rehab. If it's determined that the best location for them, we go over choice of agency, we make the referrals, and we work with their pair to see, okay, yes, you know, this is the right level of care. And then the case manager works with that facility to get them their research started and completed before they leave.

SPEAKER_02

Very good. That and and I think you you you hit on something that, you know, the hospital in particular has got, you know, so many different groups that ultimately serve the patient in some way. And I think uh, you know, hopefully what Leanne just mentioned gives you a bit of a flavor of of the value of case management. I mean we've got a lot of experts in a lot of different areas, and case managers are really critical in getting people the resources they need to get better once they're done with the hospital. Some people might, you know, feel like the hospital's trying to get you out of the hospital, but really what they're trying to do is make sure that you've got all that you need to have the best life once you're you don't need to be at the hospital anymore. And and they really play an incredibly valuable role in that. They're really one of the many advocates, but a big advocate for the patient in getting them somewhere. And uh they do experience some challenges in in finding placement opportunities, whether they're full or they some places won't take a patient. But uh hopefully for you guys listening here, you you get a real flavor that the when you meet a case manager and they talk to you about all this stuff, you you understand the key role they play in helping you or your loved one, you know. And if in a situation where you can't feel you don't feel like you can take care of mom or dad, you know, that's a factor that gets taken into account that the work that they do.

SPEAKER_03

Absolutely. And they work really as the liaison, right dad in the center of it, between everybody. I mean, with your physician, with the post-acute agencies, those type of things. They're there to help you navigate these waters that are I mean, personally, it's it's newer for us dealing with elderly parents. Man, it's harder than raising children.

SPEAKER_02

Yeah.

SPEAKER_03

So it's um they're there to help.

SPEAKER_02

Yeah, absolutely. Absolutely. I think that um uh Carla, you mentioned uh just sort of in a broad review of what post-acute care was. You talked about hospice care, and you know, another thing that people might not quite quite understand is a term called palliative care. Uh and uh why don't you talk a little bit about what palliative care is and how it it's different from hospice care? Because I think that creates some confusion. You know, our job here at the hospital is to try to take the best care evidence-based that we can. We want people to be comfortable. There are times that nothing else can be done.

SPEAKER_04

I'll be glad to. So palliative care really has been helpful

Case Management And Transitions

SPEAKER_04

across the system in coming alongside folks and helping establish goals of care. A lot of times when our patients are admitted to the hospital or they get a list of diagnoses that they are just unfamiliar with, palliative care can come alongside a patient, family, loved one, and help walk through prognosis and what their goals of care are. Sometimes folks say, My goal is to not be on so many medications, and I understand that you cannot cure my heart failure. I want to feel better. I want to wake up and take less medications. Palliative care can come alongside and work with the physician team in both the acute care or medical group of the Carolinas to make sure that they understand the patient's goals of care and that their medications are maximized. They also do a great job of coming alongside families and helping explain prognosis. And sometimes after palliative care has worked with folks who are not able to be cured, there's a there's a chronic condition that they know that they cannot reverse because we love to reverse conditions in healthcare. We love to cure. Sometimes hospice is a good route, and sometimes that's a stepping from palliative. And hospice does a really good job of knowing, walking alongside a patient who has a diagnosis of potentially prognosis six months or less. Um, sometimes that's longer. We have seen folks live longer. We don't have crystal balls, definitely, in healthcare to know lifespan, but we know that we have a condition that's not going to turn around. And hospice's goal is to maximize the days that they have. Certainly not to shorten life. Um, sometimes people get that very confused. Our goal in hospice is to help those patients live the fullest that they can in the days that they have left in the most comfortable medication management possible. That's our goal in hospice, and it's one of I it's one of my favorites in post-acute, but certainly we have a great hospice program at Spartanburg Regional Health Care System.

SPEAKER_02

Absolutely. Yeah, that's a great explanation because I think most people think we're gonna call in hospice or we're gonna execute uh palliative care, and people think that means it's a death sentence. And while you mention that we've dealing with something that might not be curable, that does not mean that someone can't continue to live as good a life as possible. It's just much better than just sitting in the hospital forever for something that can't be cured. And so, you know, hope is is that you guys listening uh get a little bit of an understanding that when those services are called in, it's really to make the loved one be as as uh comfortable and as fruitful in the time they have left. And like Carla said, uh, you know, there are people who sometimes spend over a year in hospice care because they just um uh are are still living, uh, but they really don't have something that that needs to be treated uh in a in a hospital. So I think that's a great explanation for that. We also uh you know, you talked a little bit about home health uh just in the broad overview. T talk to us about what the what kind of services are done in the home and how all that works as well.

SPEAKER_04

So home health, uh we have one of the oldest home health in the upstate. I mean, and it's interesting because home health has evolved over time. And one of the things that I enjoy most about home health, and I think is probably little known about home health, is that in home health, you have the ability to have a registered nurse or physical therapist or occupational therapist come into your home, evaluate the home situation, marry that, collaborate with your physician who sent the referral, and then be able to share what we see in the home and how we can help make sure the patients understand their medications, make sure that their home environment is safe. We may see a rug that we've seen the patient has been readmitted twice because they've gone home and tripped or fallen. And then we'll send in a skilled therapist and they'll be like, Hey, have you thought about maybe let's take this rug up? And folks don't think about those little things because we in the acute care hospitals or really any place in health care, medical group of care, they can't see into the home. So home health is really the partner to say, let's get every medication you take out of the cabinet, let's look at them, make sure we've got a full list, reconcile those back and send those back to our physician teams because we share the same health record, and really be able to partner to make sure the patient has the education they need to stay out of the hospital. That's home health's goal. Um, and we work with the acute care hospitals, Leanne's team, for readmission uh prevention and really so home health can do medication adherence education. They can do physical therapy in the home. Our nurses do a lot of wound care. The upstate has our wound population for our home health is one of the highest we know looking at market data. We have some really great nurses who can come in and change those addressings and help educate the family, safe

Palliative Care Versus Hospice

SPEAKER_04

ways to do that. And that helps keep their family members safe and infection free. They can just do all kinds of things in the home now. And insurance loves home health because it allows the patient to get care in their most comfortable environment, which is their home.

SPEAKER_02

Yeah.

SPEAKER_03

And that's where folks want to be ultimately. You want to be at home. So to be able to receive that level of care in your home environment, and it it really is the best place for the patient to receive that care when needed because it's a familiarity. I mean, you know where your bathroom is, you know the easiest way. Patients that sometimes struggle with a little bit of confusion in the hospital. Once we can get them back in that home setting and bring in the supportive services from home health, things settle back down for not only the patient but their family.

SPEAKER_02

Right. Yeah, that's a great explanation because there's a lot of evidence about people recovering much better in their home than they would at the hospital. So those of you listening, you know, let's just say play this out, you have an 80-year-old parent who needs a hip or a knee replacement. You know, the doctor is generally going to want your family member to go home. Um, and it's really not any other reason except that's what generally is best for them. The acute rehab, a skilled facility, might have its place, but if you can get someone in their home where they're comfortable, they know where everything is, have a home care team uh come in and assess uh the environment and then provide, you know, expert level care both from a nursing and uh rehab perspective, the outcomes are quite good. So if if uh you do encounter those things, that's really why the physician is talking about trying to get mom or dad home or you home, it's uh it's not for any other reason. So it's uh you also um Carla, you hit on something that I do think is worthy of uh talking about a little bit. You you talked about um Spartanburg Regional Healthcare being the first at uh some of these services that are offered, and I think there's really a whole host that our health care system has done first. I think we the first in the state or at least the upstate to do robotic surgery. Certainly the the long-term acute care hospital, Spartanburg Hospital for Restorative Care, was innovative at the time. You know, there's a lot of firsts that our organization has done, and there's been a lot of great leadership. So talk about some of the firsts within the post-acute realm that our system is engaged in and how how we've been a leader in in the state and the and the region.

SPEAKER_04

Well, you mentioned some of those. You know, the long-term acute care hospital is one of the oldest, if not the oldest, in the state, and we work nationally with a lot of other LTACs. We've had a lot of research conducted right here in Spartanburg on successful ventilator weaning. Um we have one of the best ventilator weaning rates in the state, in the United States, and uh really being able to achieve some of those great quality outcomes. We have, if not the first hospice home in the state, I'm pretty sure. We were one of the first. And it's off of Jeff Davis. The hospice home is where folks can go in and get that inpatient level hospice care if they need it. And so uh really rich in history there. It's a beautiful place if you need that type of service. And so just really coming alongside when folks are having a lot of discomfort, the hospice home is there to alleviate that and really be able to get their medication regimen

What Home Health Does At Home

SPEAKER_04

uh correct to get them home. We discharge quite a number uh from the hospice home. That's another myth, um, not a first, but a myth uh that folks always go there and they to pass. That's not really true. Our goal is to get them comfortable and get them home. And then we have I don't it's not the first, but it's has been awarded the best of the best. Seven out of eight years, our skilled unit at Spartanburg Hospital for Restorative Care has won best of the best. Our hospice has won best of the best, our home health has won best of the best. Uh so we're proud of all those things, certainly, for our healthcare system.

SPEAKER_02

Yeah, you should be. I uh you know, I think it points to for a community the size of Spartanburg, and it while it's growing, has really made large investments in health care all across the spectrum of the industry. It's it uh really have tried to be innovators to provide the community with the care that it needs. And um it's really quite a testament to the leadership over the years and the commitment of the folks that do the the real heavy lifting to provide services again in a community like Spartanburg, whether it's cancer care, uh some of the technology and and operative services we have to our post-acute care services, that we really are on the on the leading edge of trying to offer the best of the best opportunities for our community. That's uh that's I think that's a great, great testament. Uh, you know, there's a again, I my my bias is is working here that we have a great organization, but it's it's really great for people to understand that about Spartanburg Regional Health Care System. If somebody wanted to, you know, find resources for their aging parents, how might they just go about doing that?

SPEAKER_03

So for Post Acute Services, if you're looking or want some more information about any of the services we've talked about today, the best thing to do is call uh 864 560 care. Uh that's answered by a nurse on the Post Acute team, and she really helps. Patients and family navigate. My I feel like my pa mother, father, myself could benefit from home health services. What do I do next? Or I feel like we're at a spot where we need to talk to somebody about hospice. That's a great resource. It's pretty easy to remember 560 care. Uh, and then we have somebody that answers that can really help walk them through the next steps to getting them that referral.

SPEAKER_02

And I haven't used, you know, either that phone number myself or just talk to people. You know, I've been in healthcare my whole career, but there's a lot we don't know. You know, if you don't spend a lot of time, um, you know, and I'm in an acute care hospital, I don't spend a lot of time doing the work y'all do. You there's all these rules and expectations and regulations. So you do have expert people who can talk you through that. And believe me, there's a lot to take in. So these people who know a lot, uh, you've uh got easy access to folks to give them a call. They can talk you through it because we all are gonna go through the living and dying process and we're gonna have parents or family members or other loved ones that are gonna need it, and it it can be very challenging to navigate. And that's another example of where our health care system has, you know, gone well beyond just the bricks and mortar and the people care is a holistic giving people the re uh resources and information they need to make informed decisions. You uh you mentioned a little earlier uh about the uh assisted living and uh nursing homes and you know what what is covered by insurance, but does uh does do uh the many of these places take Medicare and Medicaid patients?

SPEAKER_03

So assisted livings

Spartanburg’s Firsts And Quality Wins

SPEAKER_03

living slash boarding homes, and a few of those do have some Medicaid, what they consider Medicaid beds, where if you have a Medicaid service, they'll pay for the boarding home or an uh an assisted living. But for the skilled nursing facilities, you know, it's any payer.

SPEAKER_02

Yeah. Yeah, okay. And now you also understand uh, you know, too, again, why the health care system grows like it does, because our acute care hospitals would just be full of people who don't need to be there. Um, and there's others who might need that space. There's just better places for them to get care regardless of their funding source. Right.

SPEAKER_03

They are and we and an acute care hospital is an expert in just that, in the acute care.

SPEAKER_02

That's exactly right.

SPEAKER_03

And assisted livings, they really are set up, and nursing homes are set up as the expert for that level of care. Uh, for example, i if you're you have the ability to be in an assisted living, that is the most appropriate place for you, not in a hospital where people are dealing with acute illnesses, but an assisted living where you can really thrive. You know, you're going to the dining room, you're doing those things, or if you're set to be in a skilled facility, they are the experts to meet your needs there. Right. So I think that's it's it's hard sometimes when your loved one comes into the hospital and it seems very quick that, you know, one of my case managers is coming. Hey, you were admitted today. Let's talk about what you're planning when you leave. And the reason we do that is because we don't want to catch you off guard the day of discharge. We discharge planning starts on admission for the reason. It it's it's not a benefit of the hospital, it's not a benefit of the payer. It is truly the benefit of the patient so that you're informed because as we've talked about today, there's multiple steps to get you into a skilled facility or to get you into an LTAC or a get you home with hospice. So we want to make sure all those steps are checked and it's a smooth transition. We don't ever want to have to hurry up and make a plan an hour before you're being discharged.

SPEAKER_02

Right, right. So I y'all have done a really incredible job, sort of in quick order, explaining post-acute care services, how it rolls into the acute care hospital and other things that we do. You know, for the listening audience, uh hopefully they've gotten a little bit of a better perspective on why healthcare systems have evolved like they have from a traditional acute care hospital to now having employed medical providers, other uh services. Talk to us about the the benefits of why when you go to the hospital, uh that organization is gonna, you know, provide you with many options for the next level of care. But in the event that you stay within our system, uh we believe there are benefits to that. What are some of the benefits that if somebody was to come to Pelham Medical Center and then ultimately need some post-acute care, home care, a nursing home, what have you? What's the benefit of them, in addition to just being hopefully a great service that we offer and great experience, the benefits of staying in network?

SPEAKER_04

So I'll be glad to answer that one. Initially, I would say the benefit is that we are aligned in mission, vision, and values of Smartburg Regional Health Care System. We really want to provide the care to our community in the same way that you sought care at the acute care hospitals, our post-acute services are aligned.

One Number For Post-Acute Help

SPEAKER_04

We share the same medical record with primary care offices from Smartburg Regional Health Care System, the acute care hospitals, and they can see everything that's going on in the post-acute uh division. So if you need home health, they can see how many times the nurse has come out, what's going on when the nurse comes out, what's going on with the therapist, what's happening in hospice, all the things that are really important. It takes the burden off of the family to remember to take that medication list to the primary care practice. They can see that we have reconciled the medication list from the acute care hospital to the home medications that they've seen in the home. And when you go to your physician's office, it should ease the burden off of our patients and their families. Um we really try very, very hard in our Spartburg Regional Post-Acute Division to be an extension of our medical group of the Carolinas, our physician practices, and our acute care hospital. Um we understand that we are referral-based, so um anybody can call and request services. And we we often get calls many times to that 864-560 care number. Sometimes they'll call the home health office directly. And when that occurs, our goal is to link back to that primary care physician and tell them what their patient has reached out for us for. We are just an extension of the health care system. So I think that's a huge benefit.

SPEAKER_02

No doubt. No doubt. I I've seen it work firsthand. I just with family members who, you know, started at one place and then within our system needed certain other services. That integration has really been incredibly helpful. It avoided unnecessary testing, it helped perhaps explore different testing because of previous results, and it's there for every provider to see. So, you know, doctors aren't having to say, I need records from this other place to try to deliver the best care, and uh, it works really well. And I've I've seen it firsthand. So y'all do an exceptional job. Well, you know, Carla's nice description there of how all that work sort of gets us back to just how important the case management team is. And so, you know, we've talked about all these different locations, people can get care. Uh so maybe Leanne, just talk a little bit again about how your case managers really help people uh knock through all the confusion. You know, you're you've got a sick loved one, there's emotion involved, there's stress involved. The last thing you're thinking about is, okay, I got to do these three things next. But that person can really help navigate people through our system.

SPEAKER_03

Absolutely. You got a lot of great information today, but been doing this for 28 years and have been on the other side of healthcare.

Coverage, Medicaid, And Placement

SPEAKER_03

I recognize we're in we're in a hospital setting. Some of this you may remember a little bit, but you can't remember at all. But the one thing I want you to remember is that you're not alone in this and your case manager is going to be super helpful and be the person that you say, I'm gonna ask for my case manager. I know there's venues out there, I know there's opportunities for additional care when my loved one leaves here, but I can't remember exactly how it all works. And that's when you say, I want my case manager. And that's the biggest thing. Now you know there's options for additional resources once you leave the hospital to help take care of yourself. But we want you to know once you get into the healthcare system, somebody's gonna come and walk you through the process. And they really do the steps. It is their job to know what payers cover, uh, what the requirements are under the guidelines for uh Medicare or for the agency that's accepting you. We don't expect you to know all those things because you're expected to be there and just be the loved one. You're the caregiver at home. We're the caregiver when they get here, and we want to help make sure once they leave here, we have you matched with appropriate services. So please, at any point during your stay, uh we have case managers located in the emergency room, up on each floor. They're here seven days a week. So please know that they're really going to be a great resource uh once you get in because most of the time we're meeting you in crisis or meeting you in an acute phase of your journey. So we we recognize these are hard decisions to make. You make the best decision with the information you have, and it is our goal to give you that information.

SPEAKER_02

That's a great description, and and it just reinforces there are no unimportant jobs in healthcare, and and hopefully for y'all listening, understand that when you do encounter all these different people, there's a reason they have a particular expertise, and they've done this before in a way that they can calmly get you to the information you need and the next step. Do either of y'all have any um you know personal stories you want to share about either great mentors in your life uh or uh um just uh funny anecdotes in the the daily work y'all have?

SPEAKER_03

Oh my goodness, we're uh case managers. We uh we would have to change the names to protect the guilty. Um but it's you know, I have so many mentors. Like being a part of this system for 28 years, it's a part of who I am. When I I retire in a long, long time from now, the system will always be a part of who I am. I tell folks it's not only provided a great opportunity for me, but we've lived through it. Like, like when I talk about case management and everything the system does, unfortunately, I've had to be on the other side of it. I've come in with my mother in a trauma. I've had my babies here. My father died on our hospice services. So why I'm so passionate about what we do in the acute care setting and post-acute setting

Benefits Of Staying In-Network

SPEAKER_03

is because I've lived it. And when you've had to be on the other side of it, you know, I don't I don't recommend that for anybody, but it kind of made me realize we do what we say we do. You know, we can talk about all these wonderful services, but until you've experienced, I have great confidence. So it's Bartmark Regional Healthcare Center, Pelum, Post Acute Services, we we do what we say we do. And for me as a social worker, that's the best thing I can give to our patients because we are patient-centered. We want to make sure they have the appropriate resources. So I think I've had men mentors throughout my whole career and they show up just in the most appropriate times.

SPEAKER_02

Good. Good. Carla, what about you?

SPEAKER_04

I also have had the benefit of working with many great leaders and even patients that have had such insight. I will never forget. Um, it was actually a physician who is no longer with us. He gave he said to me, he said, something I always want you to remember. He said, a square peg will fit in a round hole as long as you put enough pressure and you're persistent. He said persistence overcomes resistance. And so for our families, you know, and patients that we get the opportunity to serve. I have never forgotten that. I've also had family members in each area of our healthcare system and each area of our post-acute system. And I'm most proud that we really do say what we're gonna do. We come alongside those folks for their benefit and to help them in their healing journey. As far as if I was gonna name one mentor, it would just depend on the time of my career. Now in nursing leadership and really leading clinical teams, you know, you can look back and learn so much. And we just came out of the COVID, you know, pandemic, endemic thing that happened to everyone worldwide. And I think that we're gonna have so much learning from that, like how it's shaped us as leaders, how it's shaped our response. You know, it's hard to just point to one person. She and I've shared some similar mentors over 20 years. And it's funny, it's it's a it's an honor to serve in healthcare and just look back at how we've been able to work together and serve the community. It's really cool. That's one of the things I'm most proud of.

SPEAKER_03

I have every personal card that has been written to me from a family over the last 28 years. Yeah, those are meaningful, aren't they? They're so meaningful when you hear back from a family that you really did meet them where they are and were able to help them. That over the I have a little envelope and it's just so meaningful because that's really why we do this. That's right. Yes, that's true. Is uh is for our patients and families.

SPEAKER_02

Yeah, it does show you how important health care is and having people who really are committed. And it and like y'all said, it changes you. Uh, you know, you don't you can't be in this business for very long without it really understanding that the mission of the organization is vital and and it is who we are, and we live by that. And uh and it's really about creating

Leaning On Your Case Manager

SPEAKER_02

an experience for a family. Um because we really don't sell anything, you know. We don't sell cars, we don't sell food at a restaurant, we're taking care of people. And I think y'all both uh sum that up very nicely. I would echo the the commitment to mission and uh and that uh you know the right mentor pops up at the right time in terms of learning things. I there are things I've learned every step in my journey from you know day five in my career to now that uh that stick with you. That stick with you. So I can't thank y'all enough for giving us your time and maybe demystifying a little bit about um another important part of the healthcare ecosystem and helping people maybe better understand uh what it means to get involved with a nursing home or a home care service or an acute rehab or even an assisted living, which uh you know we're not necessarily in the business of, but there's lots of things that are out there for people to have to endure and explore, and we're here to help them with that. So thank y'all very much for y'all's time and insight.

SPEAKER_00

Thanks for having us. You're listening to the Pelham Podcast with Tony Kaye, the show that highlights all things Pelham Medical Center. Thank you for listening. For more information, visit Pelham Medical Center.com.