For hospital discharge planners

This page is for the discharge planners and hospital case managers who arrange private duty coverage for patients heading home from a NJ inpatient stay. Irina Fain has been in the NJ discharge-planning conversation since 2009, and Fain's Private Duty Home Care runs on the operational commitments a discharge team can actually schedule around.

What we deliver for your workflow

The discharge planner's job runs on time pressure and documentation gaps. FAINS is built to close both. When a discharge referral comes in, the call is answered by an operator during business hours (7 AM to 7 PM weekdays) and by a recorded line staffed by an on-call RN Supervisor rotation outside those hours. Every referral receives a call-back from an RN Supervisor within four hours. That commitment is the floor, not the ceiling. Same-day discharges get faster.

Within twenty-four hours of the referral, the RN Supervisor completes the in-home assessment (or a bedside pre-discharge assessment when the hospital allows) and drafts a plan of care that names the ADL scope, the shift schedule, the caregiver credential tier, and the escalation contacts. That draft is available to the discharge planner on request, in the format the discharge team prefers (PDF, secure email attachment, fax).

The RN Supervisor of record becomes a single named clinical point of contact for the referring hospital's post-discharge follow-up team throughout the first thirty days post-discharge. When a case manager calls to check on a patient at day seven, the same RN answers. When a physician's office calls to coordinate a follow-up appointment on day fourteen, the same RN answers. Continuity of clinical contact is the operating commitment.

FAINS confirms receipt of every discharge summary and every hospital-side communication within two hours during business hours. If the discharge team sends the summary Friday at 4 PM for a Saturday discharge, FAINS confirms receipt Friday at 6 PM at the latest and starts the intake motion before the discharge happens.

The caregiver on shift logs readmission-risk signals at every visit, and the RN Supervisor reviews the log daily during the first fourteen days post-discharge. When a signal warrants escalation, the escalation call goes out on the same day the signal is captured.

The FAINS methodology in your language

The Fain Standard is a seven-pillar framework. Translated into the discharge-planning workflow:

RN-supervised means every FAINS case has a Registered Nurse Supervisor of record. That RN is the clinical point of contact you can name in your handoff notes and reach directly. See RN-supervised private duty for the full commitment.

License-verified means every caregiver is checked against the NJ Board of Nursing CHHA registry before their first shift, with the verification date documented in the caregiver file. When your compliance department asks how FAINS handles credential audit chain-of-custody, this is the answer. See License-verified caregivers.

Four-hour minimum shift is the standard NJ private duty shift architecture. On a post-discharge case, the shift is typically longer (six to twelve hours during the acute recovery window), and the four-hour floor is documented for the family's cost planning.

Weekly transparent invoicing means the family receives a Monday through Sunday cycle invoice with hours logged per caregiver per shift. When the referring team needs to reassure a family on cost predictability during the intake conversation, FAINS invoicing is defensible under scrutiny.

Chemistry-matched caregivers is the FAINS commitment that a caregiver assigned to a case is matched to the client's personality, cultural context, and household reality (not just the ADL scope). For dementia and Alzheimer's patients, continuity of a familiar face is one of the most protective interventions in home-based cognitive care.

Twenty-four hour cancellation window and private pay only round out the seven pillars. Both are documented at the-fain-standard so the discharge team has a single reference URL.

How to refer a client

The referral pathway is deliberately short:

1. Call the FAINS line at (908) 460-8886 during business hours, or send a secure email to fain@fainscare.com with "Hospital discharge referral" in the subject.
2. Provide the patient's name, expected discharge date, discharge destination address, primary diagnosis and pertinent secondaries, current medications, functional status, DME being sent home, primary care physician contact, and family or designated caregiver contact.
3. Send the discharge summary and the H&P by secure email or fax when they are available. FAINS confirms receipt within two hours during business hours.
4. Within four hours of the initial referral call, an RN Supervisor calls back to confirm receipt and schedule the in-home or pre-discharge bedside assessment.
5. Within twenty-four hours of assessment completion, the plan of care draft is available to the discharge planner on request.
6. The first shift is typically live within twenty-four to forty-eight hours of the initial referral, faster on same-day and next-day discharge situations.

For patients discharging to Morristown, Overlook, Cooperman Barnabas, RWJ New Brunswick, JFK Edison, Trinitas Elizabeth, Newark Beth Israel, and other named NJ hospitals, FAINS has established referral coordination pathways. The named-hospital discharge pages capture the specific hand-off logistics per hospital.

If the patient is a live-in candidate, an overnight care candidate, or a 24-hour hourly care candidate, the RN Supervisor scopes the shift structure at assessment and the caregiver assignment reflects the acuity. Live-in cases require the specific caregiver credentials the NJ regulations require. FAINS staffs the tier appropriate to the case; the plan of care documents which tier and why.

How we work alongside your role

The discharge planner owns the transition. FAINS owns the private duty coverage inside the home. The scope boundary is deliberate and it stays clear throughout the case.

FAINS delivers the caregiver, the plan of care, the RN Supervisor oversight, the shift documentation, the family communication, and the payer coordination (LTCi, VA A&A, private pay planning). FAINS does not deliver the hospital's post-discharge medical follow-up, does not deliver home health nursing services reimbursed by Medicare Part A, does not deliver skilled therapy services, and does not deliver DME. Those stay with the referring hospital and the patient's other providers.

Handoff points where FAINS coordinates back to the referring team:

• Day one: FAINS confirms first shift live and sends a shift-start note to the discharge planner or the designated hospital post-discharge contact.
• Day seven: FAINS RN Supervisor sends a seven-day case check note to the hospital-side post-discharge follow-up contact.
• Day fourteen: same, at the fourteen-day mark.
• Day thirty: FAINS sends a thirty-day case status note that documents whether the case continues, escalates, or transitions.
• Any escalation event (fall, ED visit, hospital admission, significant functional decline): same-day escalation call to the hospital-side contact when the referral pathway supports it, and to the primary care physician in all cases.

Re-verification cadence: the RN Supervisor revisits the plan of care at day seven, day thirty, day sixty, and every ninety days thereafter, or immediately when a clinical event triggers the review.

What FAINS does NOT do

FAINS is a private duty home care operator. That scope is bounded. Specifically:

• FAINS does not pay referral fees to hospital staff or any professional referral partner. If a referring team is looking for a private duty partner that pays for referrals, FAINS is not the fit.
• FAINS does not accept Medicaid or Medicare as a payer for private duty home care. Cases are private pay, long-term care insurance direct pay, or VA Aid and Attendance. For Medicaid-eligible patients the referring team should route to a NJ Medicaid Personal Care Assistance provider or the JACC program.
• FAINS does not provide Medicare-reimbursed home health services (skilled nursing, PT, OT, ST). For Medicare Part A home health, the referring team should route to a Medicare-certified home health agency.
• FAINS does not deliver DME, oxygen, or infusion services.
• FAINS does not accept referrals outside its NJ service area (Union, Somerset, Essex, Middlesex, Morris counties as the current launch geography, with expansion planned).

When any of those situations apply, FAINS says so on the first call and helps the referring team identify the appropriate provider category. That is the operationally honest answer.