Clinical transition planning

Where should the patient go next?

Answer each question using the patient’s current findings and expected needs after the acute phase. The guide will identify a level of care to consider and which referral process can begin.

Current hospital need

Does the patient need to remain in the short-term acute care hospital today?

Answer only for the patient’s current status. Choosing yes does not end the screening—the next questions identify which referral process can begin while acute treatment continues.

The current setting and the next referral are separate decisions. A patient can remain in short-term acute care and still begin LTACH, inpatient rehabilitation, SNF, Home Health, or Outpatient planning.

Yes—short-term acute hospital care is still required todayAn immediate treatment, diagnostic, procedural, monitoring, or stabilization need still prevents transfer today.

View examples

A time-sensitive procedure, diagnostic decision, or specialist intervention is pending
Treatment or support is changing rapidly and requires short-interval reassessment
The patient needs rescue capability, intensive monitoring, or stabilization that the next setting cannot yet provide
A specific clinical milestone must be reached before transfer can occur

No—no short-term acute barrier currently prevents transferThe immediate acute phase is complete enough for the team to act on the next-level recommendation.

View examples

No urgent procedure or unresolved rescue need is blocking transfer
The treatment direction and transfer milestones are established
The remaining needs can be reviewed by a receiving post-acute provider

Not sure—the reason to remain in acute care is not clearly definedThe record does not identify the current transfer barrier or the milestone for reassessment.

View examples

A procedure or specialist decision may be pending, but its timing is unknown
The team has not documented what capability is needed today or what would make transfer possible

Levels of care included

Acute CareImmediate or short-term hospital stabilization

LTACHProlonged, medically complex hospital treatment

Inpatient RehabilitationIntensive interdisciplinary rehabilitation

Skilled Nursing FacilityDaily lower-intensity skilled care

Home HealthIntermittent skilled visits in the home

Outpatient RehabilitationScheduled clinic-based rehabilitation