Making Smarter Decisions About Where To Recover After Hospitalization

Every year, nearly Two million people on Medicare – most of them seniors – visit a skilled nursing facility to recover following a hospitalization. But choosing the facility could be daunting, according to an emerging body of research.

Typically, a nurse or a social worker hands out a list of facilities a couple of days – sometimes hours – before someone is a result of leave. Their email list generally lacks such essential information because the services offered or the way the facilities perform on various measures of care quality.

Families scramble to make calls and, if they can spare the time, go to a few places. Usually they're not sure what the plan of care is (what's going to recovery entail? just how long will that take?) or what to expect (will nurses and doctors be readily available? how much therapy will there be?).

If asked for a recommendation, hospital staffers typically refuse, citing government regulations that prohibit hospitals from steering patients to specific facilities which guarantee patients free choice of medical providers. (This is true only for older adults with traditional Medicare; private Medicare Advantage plans can direct members to providers in their networks.)

“The reality is that people leave patients and families without good guidance in a really vulnerable reason for their care trajectory,” said Dr. Robert Burke, an assistant professor of drugs at the University of Pennsylvania's Perelman School of Medicine.

Amid stress and confusion, seniors as well as their families frequently make less than optimal choices. Based on a 2021 report from the Medicare Payment Advisory Commission (MedPAC), an independent agency that advises Congress on Medicare, nearly 84% of Medicare beneficiaries who go to a skilled nursing facility (SNF) after a stay in hospital could have selected a higher-rated provider within a 15-mile radius. Typically, MedPAC noted, hospitals refer patients needing short-term rehabilitation to 34 facilities. (Fewer choices are obtainable in rural areas.)

Where seniors go is important “because the caliber of care varies widely among providers,” MedPAC's report notes, and this affects how fully people recover from surgeries or illnesses, whether they experience complications such as infections or medication mix-ups, and whether or not they wind up going home or to a nursing home for long-term care, among additional factors.

A recently completed number of reports from the United Hospital Fund in Nyc highlights how poorly older adults are served during this decision-making process. In focus groups, families described feeling excluded from decisions about post-hospital care and reported that websites such as Medicare's Elderly care Compare, which rates facilities by quality of care and other performance criteria, weren't recommended, simple to use or especially helpful.

What do older adults and members of the family have to know before selecting a rehab facility following a stay in hospital? Recent academic research, policy reports and interviews with experts elucidate several themes.

The Basics

Who needs post-hospital care inside a rehabilitation center? Surprisingly, there aren't any definitive guidelines for physicians or discharge planners. But older adults who've difficulty walking or taking care of themselves, have complex medical conditions and complicated medication regimens, need close monitoring or don't have caregiver support are often considered candidates with this kind of care, according to Kathryn Bowles, professor of nursing at the University of Pennsylvania School of Nursing.

Medicare will pay for short-term rehabilitation at SNFs under two conditions: (1) if an older adult has had an inpatient stay in hospital of at least 72 hours; and (2) if an older adult needs physical, occupational or speech/language therapy at least five days a week or skilled nursing care 7 days per week.

Be certain to look at your status, because not every the time you spend in a hospital counts as an inpatient stay; sometimes, patients are considered finding yourself in “observation care,” which does not count toward this three-day requirement.

Traditional Medicare pays the entire cost of a semiprivate room and therapy at a skilled nursing facility for approximately 20 days. Between 21 and 100 days, patients pay a coinsurance rate of $170.50 per day. After 100 days, a patient becomes responsible for the full daily charge – an average $400 a day. Private Medicare Advantage plans might have different cost-sharing requirements.

Nationally, the average stay for rehabilitation is all about 25 days, according to a current editorial on choosing post-hospital care in the Journal of the American Geriatrics Society.

Quality Varies Widely

In its 2021 report, MedPAC documented large variations in the quality of care provided by SNFs. Notably, facilities using the worst performance were two times as likely to readmit patients to the hospital as individuals with the best performance. (Readmissions put patients vulnerable to a number of complications. This measure applied simply to readmissions deemed potentially avoidable.) Patients in the best-performing facilities were much more likely to be discharged home and to regain the opportunity to move about than those at the worst-performing facilities.

In April, for the first time, Medicare's Nursing Home Compare web site is separating out performance measures for short-term stays in SNFs, for those who are recovering following a hospitalization, and long-term stays, for those who have severe, chronic, debilitating conditions.

Seven measures for short-term stays is going to be included: the portion of patients who experience an improvement in their functioning (such as the capability to walk), go back home towards the community, are readmitted towards the hospital, visit the emergency room, get new prescriptions for antipsychotic medications, have pain well controlled, and therefore are adequately treated for bedsores, according to Dr. David Gifford, senior vice president for quality and regulatory affairs at the American Health Care Association, which represents nursing facilities and assisted living centers. You'll also have another “star rating” for short-term stays – an overall indicator of quality.

Questions To Ask

Before making a decision on post-hospital care, older adults and members of the family should address the following issues:

Your post-hospital needs. Bowles, who has studied what kind of information patients and families find valuable, suggests people ask: What are my needs going to be throughout the post-hospital period? What sort of assistance will be needed, and for approximately how long?

Dr. Lena Chen, an associate professor of internal medicine at the University of Michigan that has published research examining wide variations in spending on post-acute care after a hospitalization, suggests asking: What is my anticipated recovery, and what do you think the most difficult parts of it may be?

What the SNF provides. Bowles also suggests people ask why the SNF is being recommended instead of home healthcare. How will the SNF meet me, specifically? What kind of medical care and therapy will I make it happen? From whom and just how often?

Carol Levine, who directs the United Hospital Fund's Families and Health Care Project, suggests that patients and families seek out information regarding facilities. Is a doctor readily available? (New information suggests 10% of patients in skilled assisted living facilities are never seen by a physician, nurse practitioner or physician assistant.) What kind of equipment and specialized services are on-site? Can the ability accommodate people with cognitive issues or who need dialysis, for instance?

Getting information early. Dr. Vincent Mor, professor of health services, policy and exercise at Brown University's School of Public Health, said patients and families should insist on seeing a discharge planner soon after entering a healthcare facility and begin the look process early. Whenever a planner comes by, “say, 'I don't care about choices: Tell me, what do you think is going to be best for me?' Be insistent,” he advised.

Burke warns that doctors don't typically know which SNF is likely to be the best fit for a particular patient – a topic he's discussed. He suggests that seniors or their own families insist they get time to contact facilities when they feel rushed. While there's considerable pressure to release patients quickly, there's also a requirement that hospital discharges be secure, Burke noted. “If we're awaiting a family to tell us which facility they want a patient to visit, we can't make a referral or discharge the patient,” he explained.