Are You Being Discharged From the Hospital to a Skilled Nursing Facility? Key Facts to Know
Key takeaways:
A skilled nursing facility (SNF) provides nursing and rehabilitative care after an injury, surgery, or illness. It differs from a nursing home, which is a permanent residence for someone who needs long-term care.
Some nursing services and therapies can happen at home. But these may not be enough to meet people’s needs. A stay in a SNF may be the best option to get back to a usual level of activity.
The hospital discharge planning process is an opportunity to decide the best course of action for an individual. Patients, family members, and the hospital care team participate in this conversation.
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After a serious injury, surgery, or illness, your hospital care team may recommend ongoing care in a skilled nursing facility, or SNF. That news may be unwelcomed if you want to get home to familiar surroundings as soon as possible. Or it might be a relief if you weren’t sure how you were going to manage at home quite yet. Either way, it helps to understand what a SNF is, and what to expect if you’re going to one after discharge from the hospital.
What is a skilled nursing facility?
A SNF might sound like the same thing as a nursing home. And that makes some people nervous. Although a SNF and a nursing home are sometimes in the same building or complex, they provide different kinds of care.
A SNF provides skilled nursing or rehabilitative care for a limited amount of time. A nursing home provides long-term care for people who are no longer able to live at home.
People most often spend time in a SNF after they’ve been in the hospital. You may need to be discharged to a SNF if you’ve had:
A stroke
A major surgery that affects your mobility
A serious illness that results in a long hospitalization
Injuries that affect movement or thinking
A condition that requires wound care or intravenous medication
Who decides that someone needs a skilled nursing facility?
People stay in the hospital for shorter periods of time today than they did in the past. Some of this has to do with cost of care and insurance coverage. But being in a hospital also comes with its own risks and complications. Hospital stays can stress your body too, and this can make the recovery process longer. So the goal is to provide the care that hospitals do best, and get your home as soon as possible.
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But sometimes people aren’t sick enough to stay in the hospital, and they aren’t well enough to go home. That may happen when an illness or injury is very serious. Or if someone is older or more frail. These people may need consistent, skilled care for a bit longer, and this is what a SNF can provide.
Discharge planning happens throughout your hospital stay. It’s a conversation that focuses on your health and safety after you leave the hospital. Discharge planning considers your:
Rehabilitation goals: Many nursing services and therapies can happen at home or in a SNF. And people’s goals, needs, and resources differ. The hospital team will talk with you about what might work best for your situation.
Safety at home: You may need to get stronger before it’s safe to go back home. Or you may need to learn ways to adapt your daily activities or improve your home’s set up to make it safer.
Social factors: Even if you’ve always been independent, you might need to rely on help from others for a while. The hospital team will talk with you and your family about who can provide different kinds of help at home.
Insurance coverage and availability: You’ll get information about all the SNF options in your area. But the availability of those options will vary. And your insurance coverage may also play a role in your discharge.
What can you expect from the care at a skilled nursing facility?
Whenever possible, it’s helpful if you or a family member can tour the SNF before you’re admitted to it. If it’s not possible to go in person, talk with people you know about their experiences. Or speak with the admissions director of the facility. You or your medical decision maker will decide which SNF to go to.
Every SNF that is certified by Medicare needs to meet certain requirements. Your care plan will be specific to your needs during your stay. But here are some of the services that you can expect at a certified skilled nursing facility:
Physical therapy (PT): Physical therapists individualize a care plan to help you get stronger and more mobile. This may include walking, climbing stairs, improving balance, and strengthening muscles. The goal of PT is to get you back to your previous level of activity and live safely at home.
Occupational therapy (OT): Occupational therapists focus on your activities of daily living (ADLs). They make sure you can do things like get dressed, bathe, eat, and do your usual activities. They may teach you how to use devices to help with certain tasks. And they’ll make sure your home is as safe as possible.
Speech and language therapy (SLP): Speech and language pathologists help with communication. Communication includes both speaking and understanding. They may also help with memory and problem-solving skills. And they help people to swallow more safely after a stroke or injury.
Social work (LSW, MSW, LCSW): Social workers in a SNF help with financial and insurance concerns. They may navigate conversations with family members, and make sure you have what you need to live at home.
Nursing staff (RNs, LPNs, CNAs): The nursing staff makes sure you get the correct medications, and takes care of any wounds or incisions. They also make sure that all the orders for your care happen as they’re supposed to. And they help you take care of yourself as you get stronger.
Medical staff (MDs, DOs): The primary care providers at a SNF are in charge of continuing any needed medical care from the hospital. When you’re first admitted, they will talk to you and do a full physical exam. And they will write orders for your medications and any therapies you may need during your stay. You may need to see your primary care provider more than once during your stay at a SNF. Or you could be seen by a physician assistant (PA) or certified nurse practitioner (NP).
What happens in discharge planning from the hospital to a SNF?
The most important member of your healthcare team is you. Talk with the doctors, nurses, therapists, and social workers about your expectations and goals. You may discover that with the right therapies and services, you have what you need to recover at home. But it also helps to understand how you might benefit from a SNF.
You always have rights as a patient. These rights include the right to refuse admission to a SNF. While you’re in a SNF, you also have the ability to make decisions about your care. While in a SNF, participation in your plan of care is required. If you refuse care, you may lose your Medicare coverage for the SNF.
If you are unable to make decisions for yourself, the hospital or SNF team will rely on your advanced directives, family members, or a legal guardian.
It will ease your transition — and improve your care — if you or your family members take part in the hospital discharge process. This includes:
Knowing your medications and what they’re for: This includes knowing if any have changed since you’ve been in the hospital.
Reviewing your medical history: Talk with your healthcare professional about your medical history. And get a good understanding of what happened during your hospital stay.
Being clear on your options: Ask about the potential advantages — and drawbacks — of receiving services at home or in a SNF.
Reviewing your discharge plan: This includes reviewing any recommended therapies and follow-up appointments.
Involving your family members or caregivers: It helps to have extra sets of eyes and ears to understand and remember the plan.
Does Medicare cover transportation and care in a skilled nursing facility?
Medicare provides benefits for up to 100 days in a SNF, for a single benefit period. A benefit period starts when you’re admitted to a hospital or a SNF. And it ends when you haven’t received care in a hospital or SNF for 60 days in a row.
Medicare Advantage plans may differ, but they include at least that amount of coverage. And there may be different levels of coverage at different facilities. Medicare supplemental insurance policies may cover additional costs, depending on the plan.
Original Medicare covers all services for the first 20 days in a SNF. For days 21 to 100, 80% is covered. Medicaid will cover charges in a SNF that has been certified by each state’s Medicaid program. But that’s only if all other payment options have been exhausted.
Original Medicare will also cover transportation to a SNF — if it’s medically necessary. This means it is covered only if you’re not well enough, or strong enough, to safely get there on your own. If you need transportation to appointments while you are in a SNF, coverage also depends on medical necessity. Some Medicare Advantage plans and supplemental insurance plans may also cover this cost.
The social workers and care managers at the hospital and in the SNF are the best people to ask about coverage for your particular circumstances.
The bottom line
SNFs provide nursing and rehabilitation services after a hospital stay. Common reasons to spend time in a SNF include major surgery, an accident, or a serious illness. The goal is to provide you with a safe place to recover and receive the therapies that get you back to your normal routine and activities. Some therapeutic services can happen at home or in a SNF. Your hospital team can help sort through the potential advantages and drawbacks of each option.
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