If you (or a loved one) are preparing for a discharge from the hospital, it’s not always obvious where to go to recover. Most of us prefer to go to our own homes, with our comfortable beds, our favorite foods, and with friends and family nearby. However, that is not always an option. If you are recovering from major surgery or an accident, you might need a skilled nursing facility. The days of long hospital stays to recover are over. (And that is a good thing since patients are exposed to many dangers in hospitals, including infections and medication errors – read our eBook for more information.) Instead, patients leave hospitals while they are still pretty sick and/or impaired, which makes the decisions about next steps critical. How do you decide where to recover after the hospital?
What are the options upon hospital discharge?
Of course, when leaving the hospital, many patients go directly home. However, going straight home only works well when patients aren’t too sick or impaired, or when patients, family, and/or paid caregivers can handle the required care. Obviously, that is not always the case. When patients cannot go home, a skilled nursing facility is usually the next step.
What are the different kinds of care facilities?
Long-term care facilities are facilities that provide care for people who cannot manage independently. The different types of facilities have similar sounding names, so it’s easy to get confused. Here’s a quick summary:
- Skilled nursing facilities typically provide daily medical care for patients recovering from a specific incident, such as a hip replacement or a stroke. Their skilled nurses and therapists treat, manage, and observe a patient’s condition, and evaluate his/her care. They usually have specialized staff on-site such as speech-language pathologists, physical therapists, and rehabilitation specialists. These facilities are also referred to as rehab facilities. Patients generally stay at these facilities for a defined amount of time while they recover from an incident.
- Nursing homes provide long-term “custodial care”, which helps the patients with daily life activities, such as bathing, dressing, using the bathroom, and eating. They usually do not have specialized medical practitioners, such as physical therapists, on-site. People may stay in these facilities for months, or even years.
Most likely, after a hospital stay, a patient will either go home or to a skilled nursing facility.
Talk to the medical team and case manager.
The patient and his/her family should discuss the patient’s needs with the medical team and the case manager (sometimes referred to as discharge planner – for this post, the term case manager also signifies discharge planner).
Work with the medical team and case manager to:
- Discuss the patient’s condition and the likely symptoms or potential problems.
- Create a detailed list of all the tasks that will be required – medical care as well as help with daily living activities.
- Learn the expected time frame for recovery.
- If the patient goes home, what kind of equipment and care is recommended? Who will arrange for and provide the equipment and care?
- Find out about what services and facilities insurance will cover. Don’t assume insurance will pay for a patient’s stay in a skilled nursing facility.
- Determine what type of transportation the patient will need to leave the hospital and who will arrange it.
How do you decide between home or a facility after discharge?
The information gathered during your conversations with the medical team and case manager will help you decide the next best step for the patient (and for the family). Be realistic about the patient’s needs and the abilities of the patient, family member, and/or paid caregivers. Who will perform the required medical tasks? What about activities of daily living, such as using the toilet, eating, bathing and dressing? Can specialists, such as physical therapists, come to the home to provide needed services? If the patient, family and/or paid caregiver cannot manage all the required tasks, then a skilled nursing facility might be the best option.
Finances might have a large influence on your decision. In many cases, Medicare or private insurance covers the cost a stay at a skilled nursing facility. But not always, so do your research on coverage before making a final decision. In contrast, if a patient goes home but requires paid caregivers, it is likely the patient and/or the family must pay for these services themselves.
Nothing is perfect.
Caring for a patient at home can be stressful for everyone involved. But nothing is perfect in these situations, including skilled nursing facilities. Even the “best” facilities have issues that range from frustrating to dangerous.
Quality of care issues.
Unfortunately, the quality of care provided at skilled nursing facilities varies widely among facilities, which can impact recovery. Inattentive care, medication errors, infections and other issues make recovery from surgeries or illnesses harder. Moreover, poor quality care makes it more likely that patients will end up either back in the hospital or in a nursing home.
A 2018 report by the Medicare Payment Advisory Commission (MedPAC) shows large variations in the quality of care provided by skilled nursing facilities. Importantly, the facilities rated with the worst performance were twice as likely to send patients back to the hospital with as those with the best performance. (Note that this only applies to readmissions considered potentially avoidable.) Furthermore, patients at the best-performing facilities were much more likely to go home and to regain the ability to move around than those at the worst-performing facilities.
What are some examples of quality issues?
Medication errors are common.
Medication errors, which can cause serious harm and even death, are common in facilities. The Institute of Medicine estimates there is at least one medication error per patient every day in hospitals and care facilities! Furthermore, the report also states there are 1.5 million preventable adverse drug interactions each year in hospitals and care facilities. Although medication errors can occur at home as well, one has more control over medications when at home. Read this blog post to learn more: Reduce the Risk of Medication Errors in Long-Term Care Facilities.
There is a risk of infection.
The risk of infection increases in a facility versus a private home. Patients can get infections through airborne contaminants and when staff transfer germs from one patient to another. Patients in long-term care facilities are at risk for respiratory tract infection (including pneumonia), gastrointestinal infection, urinary tract infection, and skin and soft tissue infection. Read my blog post to learn more about reducing the risk of infections: How Can Patients Protect Themselves from Hospital Infections?
Inattentive care can harm patients.
Staffing issues at skilled nursing facilities present a challenge that can be frustrating, and sometimes dangerous, for patients. Working in these facilities is hard work, with nominal pay and long hours. Unfortunately, there is a shortage of available workers and turnover is high. Conservative estimates of turnover are between 45-66%. Moreover, 1 in 4 nursing assistants are actively job hunting. As a result, facilities struggle to hire and keep employees.
In some cases, staffing struggles mean there are not enough employees to provide a safe, expected level of service. And high job turnover means that many employees are learning a new job, while others have one foot out the door. What does this mean for patients? Long waits for medications and assistance which can lead to a range of issues including delays in pain reduction and uncomfortable waits for toileting help.
Patients and staff must abide by rules and regulations.
When patients in a facility need something that is not part of their medical plan, it’s not easy. When patients are at home, they can quickly and easily take over-the-counter medications without any hoopla. But in a facility, any new medication must be approved by the doctor and is therefore not available immediately. It sounds like this might not be a big deal, but it can be frustrating and lead to unneeded discomfort. For instance, if a patient feels heartburn while at home, he/she can quickly take an antacid, and get relief. In contrast, if a patient is in a facility, he/she might have to wait hours for approval.
Additionally, sleeping can be challenging in a facility. Nurses and other staff wake patients up when it’s time for medication, services or wellness checks. It can be hard to sleep undisturbed through the night and can be even harder to nap during the day.
It’s not all bad.
Despite these shortcomings, a skilled nursing facility might be the logical choice as it can provide the level of care many patients need while recovering after a hospital discharge.
What if you think the patient isn’t ready to leave the hospital?
If you believe the patient is not ready to be sent home or to a different healthcare facility on the date recommended, speak up to express your concern for the safety of the patient. If the case manager does not agree with your assessment of the safety risk to the patient, ask to speak to a patient advocate and/or the patient’s lead doctor. You might succeed in delaying discharge to a later date more appropriate to the patient’s situation.
How to choose a nursing home or skilled nursing facility?
Read this blog post for information to help you choose the best facility for a patient’s needs.
For more information read these posts:
- Nursing Home Safety Issues.
- Medication Errors in Long-Term Care Facilities – One Patient’s Cautionary Tale.
- Tips for Hospital Discharges.