After the Hospital: Recovering in a Skilled Nursing Facility

Whether from illness or injury, the chances of ending up in the hospital increases with age. A Center for Disease Control report showed that in 2017, 15% of those aged 65 years and older were admitted to the hospital in the past 12 months, compared to less than 6% of those aged 18 to 44 years.

Of course, the goal of hospitalization is for the patient to regain health and be discharged. However, not everyone leaving the hospital is ready to go home. Many patients still need continuing, though temporary, medical care at a less intense level than in the hospital. In many cases, this care is provided at a skilled nursing facility (SNF).

Formerly known as "nursing homes," these facilities commonly accept two types of patients. The patients most often associated with skilled nursing facilities suffer from long-term, acute conditions that require permanent, around-the-clock care. The other population served by skilled nursing facilities consists of patients recovering from illness or injury who need care until they are well enough to return home. In this role, SNFs are classified as post-acute rehabilitation facilities.

Preparing to Leave the Hospital

Patients and their families benefit by planning ahead for post-hospitalization care. In cases where hospitalization was scheduled, such as for elective joint replacement surgery, preparing for care after discharge can be accomplished methodically. Medical practitioners will prescribe therapies, medications, and other actions to be taken after hospital discharge. Armed with this information, arrangements for the patient's post-discharge care can be made in advance.

However, in situations like sudden illness or accidents, post-discharge planning can only start once the patient has been admitted to the hospital. Meeting early on with medical personnel to sketch out possible scenarios will provide patients and their families with information about potential next steps.

It is essential to find out who coordinates discharge planning for the hospital. This person may be a discharge nurse or a hospital social worker. Whoever it is, meeting with this person will begin the discharge planning process. Even though it may be too soon to discuss specifics, understanding what information this individual needs will smooth the process when the time comes.

Another helpful resource is the Discharge Planning Checklist published by Medicare. It provides a wide-ranging list of items to help patients and their families stay on track for a successful transition after discharge.

A crucial detail regarding the length of the hospital stay and subsequent SNF coverage is the Medicare "3- day rule." A patient must be in the hospital for three days to qualify for Medicare payment of any follow-up SNF care. Time spent in the emergency department or on an outpatient basis doe not count in the three days.

Options After the Hospital

Common post-discharge scenarios are:

• Returning home - this may involve family or outside caregivers continuing to support the patient until independence is restored.
• Placement at a senior living facility – this could happen if the injury or illness caused a permanent deficiency requiring a level of care not possible at home.
• Temporarily transfer to a skilled nursing facility – the patient's condition is expected to improve, so SNF services can support the healing process.

In this last situation, the patient's stay may last anywhere from a few weeks to several months, depending on the severity of the condition. Nevertheless, the patient is expected to recover to a former level of independence or somewhere close.

A further objective is preventing readmission to the hospital. Unfortunately, a 2014 National Institutes of Health study found that between 5-18% of Medicare patients were back in the hospital within 30 days of being discharged from an SNF or other post-acute rehabilitation facility.

The services provided in this post-hospital setting typically are:

• Wound care
• Dispensing medication
• Rehabilitation services like physical, occupational, and speech therapy
• Help with dressing, bathing, toileting, eating, and mobility

What to Look For in a Post-Acute Rehabilitation Facility

If a patient and family can plan ahead, researching possible post-hospital facilities ahead of time can increase the possibility of finding the best setting for the patient.

Some areas to investigate are:

1. What is the proximity of the facility to family and friends?
2. What are the costs, and what is covered by the patient's insurance?
3. What other expenses (internet, television, phone) will the patient pay out-of-pocket?
4. What treatment and therapies are provided, and how often?
5. What other amenities and services are available?
6. What is the facility's Medicare rating?
7. What is the ratio of staff-to-patient?
8. What experience does the hospital have with the facility in terms of re-admission?

An onsite visit to one or two top choices will provide more information for making the decision. Allowing the patient to visit may take some of the mystery and anxiety out of the impending medical procedure and follow-up care.

If a patient and family can't plan ahead due to emergency hospitalization, the hospital discharge planner can provide a list of recommended facilities. This person can answer most of the questions above to help find the right setting.

Planning a Successful Post-Acute Rehabilitation Experience

A 2013 National Institutes of Health study listed best practices to increase the patient's potential to successfully transition back into everyday life. Find out from the discharge planner how the hospital and SNF will collaborate after discharge and follow these guidelines.

• Comprehensive discharge planning
• Complete coordination and communication of information between the hospital and skilled nursing facility
• Availability, timeliness, clarity, and organization of information exchanged
• Focus on medication safety
• Educating patients about self-care
• Organizing social and community supports
• Follow-up monitoring and managing symptoms from discharge, through transitional care, and return home.

The more patients and their families can educate themselves about the continuum of care from hospital to skilled nursing facility to ongoing care after returning home, the greater the likelihood of a quick return to full health.

Learn more about senior living on Cantissimo Senior Living's Housing Resources and Long-term Care Resources pages.