A placement partner that checks acuity first.

What you need from a placement partner

You have a length-of-stay target, a readmission metric, a patient who has been medically ready for four days, and a plan that just fell through at 3pm. What you need is competence, speed and candour, in that order.

The readmission problem, specifically

Medicare’s Hospital Readmissions Reduction Program adjusts payment based on 30-day unplanned readmissions across conditions including heart failure, pneumonia, COPD, AMI, CABG, and elective hip and knee replacement. The maximum penalty is 3% of base Medicare inpatient payments, and in recent programme years around four in five hospitals have taken some penalty. (CMS, KFF.)

A misplaced patient is a readmission waiting to happen. A supervisory-care home that accepts a resident needing directed care will call 911 the first time there is a fall or an escalation, and that bounce-back is attributed to your discharge, not to the home’s admission decision.

Our position is simple: the acuity review happens before the placement. Stephanie holds a bachelor’s degree in nursing and has experience running a licensed care home, so she reads the H&P, the medication list, the transfer status, the behavioural notes, and the wound care — and matches them against what a given Arizona licence level is permitted and staffed to handle. When the setting you are hoping for will not work, you will hear that from us while there is still time to plan, rather than at readmission.

Referrals we actively want

These are the patients who wait on units because they are hard to place. Send them.

Arizona levels of care, and what each can hold

Arizona DHS licenses assisted living homes (ten or fewer residents) and centres (eleven or more) at three service levels. Matching to the right one is the difference between a placement that holds and one that does not.

Level	Broadly appropriate for	Watch for
Supervisory care	Independent in ADLs; needs oversight, medication reminders, meals	Any hands-on ADL need is out of scope — a frequent source of failed placements
Personal care	Hands-on assistance with ADLs; transfers with assist	Continuous nursing need and significant behaviours
Directed care	Residents unable to direct their own care — moderate to advanced dementia	Secure/locked capability is a separate question from the licence level

General guidance only. Individual homes vary in what they will accept regardless of licence level, which is precisely why we verify per patient rather than working from a directory.

After the discharge

The first thirty days are when placements fail, so that is where we spend attention: contact after the move, again within the first week, and again at thirty days. If a placement is deteriorating, we help move the resident before it becomes a readmission. If a placement we made comes back to you, we want the call.

Heaven Sent Senior Placement is a placement and referral service, not a healthcare provider, and does not deliver nursing care.