Elmhurst: from a hospital discharge to Medicaid home care at home

A large share of Elmhurst's home care requests begin in a hospital bed. The public hospital on Broadway serves the neighborhood regardless of insurance, and its discharge planners send people home every day with instructions to "get an assessment." This page explains what that assessment is, who does it, and what follows, for households in the walk-ups and mid-rise buildings between Broadway and Queens Boulevard. Elmhurst is among the most linguistically mixed places in the country; Spanish, Chinese, Bengali, and many other languages are spoken here, and interpreters are available on every line named below if requested when you call.

ZIP 11373 covers most of Elmhurst (approximate; verify with USPS), roughly from Roosevelt Avenue south to the Long Island Expressway and east to Woodhaven Boulevard. County: Queens.

NY Connects, 1-800-342-9871 (Relay 7-1-1); say "Queens." It is the right call if a discharge planner used words you did not recognize. HIICAP, 1-800-701-0501, handles free Medicare counseling; say "Queens." The nearest in-person NYC Aging HIICAP sites are the RAICES / Corona Senior Center at 102-47 43rd Avenue (718-458-7259) and the Sunnyside Community Senior Center at 43-31 39th Street (718-784-6173 x411), both by appointment. The 7 train along Roosevelt Avenue reaches Corona in a few stops.

Elmhurst Medicaid is HRA, citywide, 1-888-692-6116. HRA's long-term care page says home care programs all require Medicaid and lists the DSS OneNumber, 718-557-1399, for home care questions; borough CASA offices are listed on nyc.gov/hra. If a hospital social worker started a Medicaid application for you, ask for the case number before you leave.

1. Medicaid must be active. A pending application is not enough for NYIA to schedule. Check status with HRA.
2. Call NYIA at 1-855-222-8350 (TTY 1-888-329-1541). If you are already in a Medicaid managed care plan and not yet receiving services, the NYIA FAQ says to contact your plan, which will call NYIA with you on the line. If you are not in a plan, contact the local social services district, which for Elmhurst is HRA.
3. A nurse's community health assessment, then a clinical appointment. The FAQ says these can happen at your home, a relative's home, or a facility where you are receiving services, which matters if you are still in rehab.
4. An outcome letter. It reports whether the person meets the requirements to request personal care or consumer directed services, or to enroll in a Managed Long Term Care plan.
5. New York Medicaid Choice (1-800-505-5678, long term care 1-888-401-6582) for MLTC plan selection when that is the route.
6. The plan's own visit and care plan, then services usually begin after the enrollment date. Hours are the plan's decision.

• Leaving the hospital with no Medicaid number and a stack of forms. The single most useful thing to get before discharge from the Broadway hospital is confirmation of Medicaid status and, if an application was filed, its case number.
• Thinking the hospital's own home care referral replaces the independent assessment. The Department of Health's program page says the assessment must be done by an independent nurse and clinician with no prior relationship to the person. The hospital's evaluation is helpful evidence, not a substitute.
• Asking for hours on the NYIA call. The scheduler cannot answer that, and neither can this site. Hours are set later in the plan's person-centered service plan.

Orientation only: NYC Health + Hospitals / Elmhurst at 79th Avenue and Broadway. The Elmhurst Avenue and Grand Avenue stations on the M and R and the 7 along Roosevelt Avenue are the practical links to the Corona and Sunnyside counseling sites.