For Professionals
Rehab to assisted living: a transition guide for nursing home teams
For social services directors moving short-term rehab residents to assisted living or memory care.
- Start the conversation at the first care plan meeting, not the week coverage ends
- Clarify the payer: Medicare days remaining, Medicare Advantage authorization, private pay, Medicaid
- For private pay, refer early; for Medicaid, coordinate with the ADRC and the long-term care plan
- Gather: AHCA Form 1823, medication list, recent history and physical, therapy notes on mobility
- Plan transport and a warm handoff to the receiving community nurse
General information only, not medical, legal or financial advice. Programs and amounts change; confirm with the official source or a qualified professional.