Form with Patient Information and Facility Choices



STRONG MEMORIAL HOSPITAL

Social Work Division

Placement Patient Information Form

Patient Admitted from:___________________________

Social Worker Unit_____________ Expected D/C________________ Date: Date:

Full Inpatient Admit_____________

OBS Status _____________

Outpatient Status _____________

Previous Hospital Stay within the last 30 days (include dates):________________________________________________

Expected Discharge Disposition: SNF Rehab with D/C: Home Adult Home/ALF_________________ Long Term w/ therapy Long Term Terminal Vent Unit Behavioral Unit

Dementia ( ) Secured Unit ( ) Wander Guard Other ____________________________________

Facility Choices: Please mark in order of preference 1-10 (1 being the first choice)

| |Monroe County: | |

|___Aaron Manor* |___Highlands Living Center* |___Penfield Place* |

|___Baird Nursing Home* |(UR Medicine) |___Rochester Friendly Home* |

|___Brightonian* |___Hill Haven (Rochester Regional Health) |___Shorewinds* |

|___Brighton Manor |___Hurlbut* |___St. Ann’s (Irondequoit) |

|___Creekview |___Jewish Home |___St. Ann’s (Webster)- No rehab |

|___Crest Manor* |___Kirkhaven |___St. John’s |

|___Edna Tina Wilson |___Latta Road East |___Unity Living Center |

|(Rochester Regional Health) |___Latta Road West |(Rochester Regional Health) |

|____Elderwood at Lakside Brockport |___Maplewood |___Wedgewood Nursing Home* |

|___Episcopal Church Home* |___Monroe Community Hospital* |___Wesley Gardens* |

|___Fairport Baptist Home* |___New Roc Rehab & Nursing Center |___Woodside Manor* |

|___Hamilton Manor |___Park Ridge Living Center |Surrounding Counties |

|___Highlands at Brighton* |(Rochester Regional Health) |(see next page) |

|(UR Medicine) | | |

For Placement Office Use Only

Dates Opened: ____________ Date Packet Received____________________________

____________ ____________ Discharge Date_________________________________

____________ ____________ Discharge Facility

____________ ____________ Entered in e-Record Opened in ePartner

Allegany County

___Absolut of Houghton

___Cuba Memorial SNF

___Highland Park

___Jones Memorial Swing Bed Unit

___Wellsville Manor

Cattaraugus County

___Absolut of Allegany

___Absolut of Salamanca

___Gowanda Nursing Home

___Olean General Swing Bed Unit

___Pines of Machias

___Pines of Olean

Cayuga County

___Auburn Nursing Home

___Finger Lakes Center for Living

___Northwood at Moravia

___The Commons on St. Anthony

Chemung County

___Bethany Manor

___Chemung County Nursing Facility

___Elcor Nursing Home

___St. Joseph’s Hospital & Nursing Home

Genesee County

___Batavia Nursing Home

___Batavia VA

___Leroy Village Green

___NYS Veterans Home (SNF)

___Premier Genesee Health & Rehab Center

Livingston County

___Avon Nursing Home

___Conesus Lake SNF

___Livingston County Nursing & Rehab

Ontario County

___Canandaigua VA

___Clifton Springs Hospital & SNF

___Elm Manor

___Living Center at Geneva North & South

___MM Ewing Continuing Care Center

___Ontario Center

Orleans County

___Medina Hospital SNF

___Orchard Manor

___The Villages of Orleans

Revised 4/16/18

Oswego County

___Michaud Residential Health

___Morningstar Residential Care Center

___Pontiac Nursing Home

___St. Luke’s Health Services

___The Manor at Seneca Hill

Schuyler County

___Seneca View at Schuyler Hospital

Seneca County

___Huntington Living Center

___Seneca Nursing & Rehab

Steuben County

___Absolut of Three Rivers

___Bath VA

___Corning Center

___Elderwood at Hornell

___Hornell Gardens

___Steuben Center for Rehab & Healthcare

___Taylor Health Center

Tioga County

___Elderwood Health Care at Waverly

___Riverview Manor

Tompkins County

___Beechtree Care Center

___Cayuga Ridge

___Groton Community Health Care Center

___Kendal at Ithaca (only accepts Life Care Residents)

___Oak Hill Manor

Wayne County

___DeMay Living Center

___Newark Manor

___Sodus Rehab

___Wayne County SNF

Wyoming County

___East Side Nursing Home

___Wyoming County SNF

Yates County

___Homestead SNF

___Penn Yan Manor

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*UR Medicine Providers

SW/Placement Office Notes:

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