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Helping Patients with Skilled Nursing or Other Long Term Care Needs

Resources, information and a support line to assist hospital staff in placing individuals with skilled nursing or long-term care needs

Table of Contents

General Guidance and Information

  • COVID-19 positive patients: If trying to place an individual infected with COVID-19 who needs skilled nursing facility level of care, providers should contact facilities with dedicated COVID-19 isolation space.
    • MassHealth has established the Isolation Space Program to ensure dedicated capacity for individuals who are infected with COVID-19 who need ongoing skilled nursing level of care. Facilities participating in the program have met certain quality criteria and are required to admit COVID-19 residents from the hospital and other settings.  Discharge planners should refer to this list of participating facilities, updated on a weekly basis, to identify facilities that have created these dedicated isolation spaces.
  • General LTC admissions: If trying to place non-COVID patients and/or individuals with specialized skilled nursing or other long-term care needs, you should contact facilities within your region to inquire on bed availability and specific patient care needs. There are a number of reasons why your preferred long-term care facilities are currently not admitting residents, including a temporary state-imposed or voluntary admissions freeze. The map included in the “Regional Distribution of LTC Facilities” section below is intended to serve as a resource to identify available facilities in your region.  
  • MassHealth coverage: For individuals in need of MassHealth coverage, information on the application process can be found here. For further assistance with coverage or eligibility issues, please contact the MassHealth Customer Service Center (800) 841-2900.

Regional Distribution of LTC facilities

The map below is intended to serve as a reference for identifying available facilities within your region including those that may be accepting new residents, those that have a dedicated COVID-19 isolation space and those that have substantial experience providing services to residents with behavioral conditions.

This resource is not reflective of available bed capacity and thus discharge planners should contact the facility for availability. 

This map will be updated twice per week, with new versions being posted each Wednesday and Friday by 4pm E.T.

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  • Legend: Gray = Under DPH Admissions Freeze; Orange = Not under state-imposed admissions freeze, may be accepting new admissions
  • Click on markers to expand information on facility name, address, phone number, and Behavioral Health (BH) Experience.
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Admissions Freeze: Facilities under a state-imposed temporary admissions freeze. Facilities are subject to such an admissions freeze when certain conditions are met (e.g., >10 new cases in last 7 days, infection control deficiencies, etc.) and DPH has determined an admissions freeze is necessary to protect the health and safety of residents and prevent further COVID-19 transmission. Stopping admissions enables facilities to focus resources such as staff and PPE on the health and safety of their current residents and enables them to stabilize before taking on new residents. An admissions freeze will remain in place until DPH has determined that conditions have improved, and the facility is ready to safely care for new residents. The above map will be updated twice weekly as admission freezes are lifted and/or put into place. Please check back frequently as this information may change.

Nursing Facilities with behavioral health experience: Facilities that have demonstrated experience providing nursing facility services to residents with behavioral conditions are noted in their descriptions. This list is not intended to be exhaustive and will be updated on a weekly basis. All nursing facilities are required to provide needed behavioral health supports in accordance with each resident's care plan. Discharge managers should contact facilities for more information regarding clinical specialties and patient needs.

Regional Distribution of Facilities Providing Post-Acute Chronic and Rehabilitation Services

Non-acute hospitals provide a wide range of services in order to support patient care after an acute care hospitalization.  They are defined using the Massachusetts Department of Public Health (DPH) and Department of Mental Health (DMH) license criteria and fall into one of the following categories:

  • Long-Term Acute Care Hospitals (LTACs): Hospitals that typically provide longer term care where the average length of stay is more than 25 days. 
  • Inpatient Rehabilitation Hospitals (IRF): Hospitals that provide intensive post-acute rehabilitation services, such as physical, occupational, and speech therapy services.
  • Specialty Care Hospitals: Hospitals that provide care for unique populations like children.
  • DMH or DPH Hospitals: Hospitals that provide services for those with otherwise limited access to facilities providing such care.

The map below is intended to serve as a reference for identifying available facilities within your region including those that may be accepting new residents. Data is self-reported on a biweekly basis and may change by the day. Discharge managers should contact facilities for more information regarding bed availability.

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Click on markers to expand information on facility name, address, phone number and available beds.

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EOHHS Long Term Care Discharge Support Line

Discharge support is available to assist staff from acute hospitals and/or other settings such as psychiatric hospitals, who are working with current patients in need of facility-based long-term care (SNF,RH or LTAC) post discharge.  

This support line is meant to supplement comprehensive discharge planning efforts as required per applicable DPH, MassHealth and CMS regulations and contracts. Providers and Discharge staff are expected to utilize the resources above before contacting Discharge Support. This service is a resource meant for use by provider staff (discharge and case managers) only.  Families and community members who have questions about the care their loved one is receiving during the COVID-19 outbreak should call The Nursing Home Family Resource Line at (617) 660-5399.

When to contact Long Term Care Discharge Support:

  • Discharge staff should contact the Discharge Support team when they have exhausted the above resources and challenged to find a long-term care placement.
  • For MassHealth members enrolled in a MassHealth managed care plan, please contact the member’s managed care plan to coordinate discharge planning prior to contacting the support line. Please see the Accountable Care Partnership Plan (ACPP) Contact List for Discharge Planning for contact information.

How to connect with the Discharge Support Team:

Nursing home consumer information

Information on long-term care options in Massachusetts, individual nursing homes and resident rights among other resources can be found on the Nursing Home Consumer Information webpage. This webpage includes:

  • The Nursing Home Survey Performance Tool, a state resource which includes DPH quality scores on an individual facility’s administration, nursing, resident rights, food services, and environmental categories
  • Nursing Home Compare, a federal resource from the Centers for Medicare and Medicaid (CMS) that contains detailed information about nursing homes nationwide, including their CMS five-star rating
  • Ombudsman Programs, which are advocacy programs available for or on behalf of residents at assisted living facilities, long-term care facilities and those in community care. The ombudsman service offers a way for older adults to voice their complaints and have concerns addressed so they can live with dignity and respect.

In addition, the Commonwealth has created the COVID-19 Family Information Center to provide the latest resources and information for families and loved ones of residents in nursing homes during the COVID-19 pandemic.

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