Home / After a hospital stay
Hospital discharge, Nassau and Suffolk
Coming home after a hospital stay takes planning. The first weeks at home are when a missed medication, a skipped meal, or a fall can set recovery back. Bryan Skilled Home Care Inc. has been a Licensed Home Care Services Agency on Long Island since 2011. From our office in Amityville we serve Nassau, Suffolk, and Queens, and once hours are authorized, we match an aide to the schedule.
Call (631) 608-8523 Mon to Fri, 9 to 5
Every hospital has staff who plan the move home, called a discharge planner, case manager, or social worker. Ask for them early in the stay, not on the last morning. They can tell you the expected discharge date, what your loved one will need at home, and what has already been ordered.
Before you leave, make sure you have, or know when you will get:
If the plan does not seem safe for home, say so before discharge. If your loved one has Medicare, the hospital gives a written notice explaining how to appeal if you think the discharge is too soon.
This is also the moment to call a home care agency. The discharge planner can send a referral, or you can call us yourself with the discharge date and the town.
Every recovery is different, and the doctor's instructions come first. Here is what the first stretch at home usually involves.
Home health aides (HHA) and personal care aides (PCA) follow the plan of care, and our nurses oversee it. In the weeks after discharge, that usually covers:
Help with bathing, dressing, grooming, and toileting, with respect for privacy. See personal care.
Help getting in and out of bed, walking around the house, and a walk-through for loose rugs, grab bars, lighting, and a clear path to the bed and toilet. That walk-through is part of the visit, not a separate program.
Meals that fit the diet in the discharge instructions and care plan, and shopping as authorized. See nutrition management.
Aides give medication reminders as part of the plan of care, with nurse oversight, to help keep a new or changed schedule on track.
A familiar face and a steady routine. Aides report changes, such as new confusion or poor appetite, to the nurse and family so problems are noticed early.
Our nurses complete assessments, shape the plan of care, and adjust it as recovery changes.
If cognitive changes are part of the picture, see mind and memory care. Our aides complete state-approved home health aide training and do only the tasks the plan of care allows.
Any one of these is worth a call. There is no charge to talk it through.
Print this or keep it on your phone. Most of it can be done before discharge day.
We are a LHCSA. Most families use one of these, and some use two together. We will help you work out which applies.
For ongoing hours, most Long Island adults with Medicaid get home care through an MLTC plan. We work with the MLTC plans Aetna, Fidelis, Senior Whole Health/Molina, and VNS. Plan participation can change, so call (631) 608-8523 to confirm yours. For how eligibility, the state assessment, and plan hours work, see Medicaid home care on Long Island.
When authorized, we provide waiver services in Nassau and Suffolk. Hours go through the waiver coordinator. For a brain injury, see TBI waiver home care.
Paying privately skips the wait for plan authorization and is often the fastest way to cover the first days at home. Some families use it to bridge until plan hours start, or to add evening or weekend hours. Call for current rates.
We work with long-term care insurance; have the policy details ready when you call. Workers' compensation can pay for home care after a job injury once the carrier authorizes it.
We do not bill Medicare. If discharge paperwork orders Medicare home health (skilled visits billed to Medicare), a Medicare-certified home health agency provides it; ask the discharge planner for one. Medicare does not pay for personal care when that is the only help needed (see Medicare's home health page). For aide hours Medicare will not cover, call us.
Our only office is in Suffolk, at 15 Albany Avenue in Amityville. We serve families coming home from hospitals and facilities across Suffolk. Care on the East End is based on availability.
Home care in Suffolk CountyAmityville sits right at the Nassau line. We serve Hempstead, North Hempstead, and Oyster Bay, plus Glen Cove and Long Beach.
Home care in Nassau CountyWe also arrange care after discharge in Queens. The full picture is on our service area page.
We take referrals from hospitals, SNFs, MLTC care managers, waiver coordinators, and physicians across Nassau, Suffolk, and Queens. Refer online through Refer a Patient, call (631) 608-8523, or fax (631) 608-8527. Coverage we work with: Medicaid MLTC, NHTD/TBI waiver, private pay, workers' compensation, long-term care insurance. Once hours are authorized, we match an aide to the schedule. We confirm receipt, including when the answer is no.
Once hours are authorized, we match an aide to the schedule. Private pay is usually the fastest path. Medicaid MLTC depends on authorization from the plan. NHTD and TBI waiver hours go through the waiver coordinator. Workers' compensation needs carrier authorization. Call (631) 608-8523 with the discharge date even if coverage is still unsettled.
The hospital discharge planner or case manager often starts the referral. Families can also call us directly at (631) 608-8523 or use the form on this page. Facilities should use Refer a Patient.
No. Bryan Skilled Home Care is a Licensed Home Care Services Agency (LHCSA), not a Medicare-certified home health agency (CHHA). We work with Medicaid MLTC, NHTD/TBI waiver, private pay, workers' compensation, and long-term care insurance. Families often use a certified agency for Medicare nursing visits and us for aide hours Medicare does not cover.
Nassau County, Suffolk County, and Queens, coordinated from 15 Albany Avenue, Amityville, NY 11701. Care on the East End is based on availability. See Nassau, Suffolk, and Queens.
A personal care aide (PCA) helps with everyday tasks such as bathing, dressing, meals, mobility, and companionship. A home health aide (HHA) can do that work and, under nursing supervision, additional tasks in the plan of care. Both follow the authorized plan.
Medicaid MLTC and NHTD/TBI waiver hours start when the plan or program authorizes them. Private pay can bridge a gap. See Medicaid home care on Long Island or call (631) 608-8523 with the discharge date.
Not always. Medicare home health ordered at discharge is provided by a Medicare-certified home health agency. Medicare does not pay for personal care like bathing and dressing when that is the only help someone needs. That ongoing aide help is what we provide, and the two often run side by side.
Yes. Many families start with private pay for the first days at home, then move to plan hours once the MLTC plan or waiver program authorizes them. Call (631) 608-8523 for current private rates.
The discharge date, the town, how care will be paid for (Medicaid plan name, long-term care insurance, or private pay), and the hours you think are needed. You do not need every answer before you call.
Aides give medication reminders at the times set in the plan of care, and our nurses review the medication schedule. Aides do not decide doses or change medications; questions go to the nurse, the pharmacist, or the doctor. See medication management.
Yes. The same steps apply when someone is coming home from a skilled nursing facility or another facility stay. The facility social worker can use Refer a Patient, or the family can call (631) 608-8523 with the discharge date.
Our office is open Monday to Friday, 9 to 5. For clients already on service, the 24-hour on-call line is (631) 608-8523, nights and weekends included. For a medical emergency, call 911.
Tell us the discharge date and where home is. A coordinator will follow up during office hours. To start care, call (631) 608-8523.
15 Albany Avenue, Amityville, NY 11701
Mon-Fri 9 to 5, 24 hour on-call
Prefer to talk? Call (631) 608-8523.
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