The days of holding patients in a hospital until they are cured are long gone. Patients are now discharged when they are “stable,” meaning that they are not actively dying. But stable, and able to go home are not the same thing. Frequently, patients are too weak to take care of themselves at home, or are not mentally capable of living alone. In those cases, patients are sent to a “Skilled Nursing Facility” (SNF) aka Rehab (Subacute Rehabilitation facility).
SNFs are paid for by Medicaid if patients are over 65 as long as certain criteria are followed: the patient needs to participate in physical or occupational therapy daily, and make progress in that therapeutic program. So, if mom or dad is unable or unwilling to participate, they will be discharged from the SNF. If they can’t participate because they are in pain or depressed, make sure the pain or depression are evaluated and treated.
Most SNFs are for profit, private businesses. They get a set daily fee from Medicare or Medicaid to deliver nursing and therapy care to patients. All of the patients’ medications, food, nursing care, aid care, and everything else, comes out of that daily fee. The more medications used by the patient, the less profit is made by the nursing facility. The more registered nurses are on staff, the less the profit. The fancier equipment, fresher food, and better staff, the less the profit – you get the idea. As a result, SNFs are chronically understaffed, and the staff that is present is underpaid and overworked.
These SNFs are not required to employ physicians, and most of them don’t. The only requirement is that they pay a physician to be a medical director – which is a purely administrative position that does not require the physician to be physically present, or perform any patient care. Physicians caring for SNF patients are outside doctors who visit the facility, see patients of their own choosing, and bill Medicare separately for their services. Medicare requires that these physicians physically examine and admit new patients within 30 days, and then only requires them to see patients once monthly unless there are immediate medical issues that require attention. These rules were written at a time when patients were far more stable before being admitted to SNFs – unlike nowadays when patients may be very very sick, and be discharged directly from the intensive care unit into a SNF. Needless to say, the regulations are completely inadequate. Insist that your loved one be seen by a physician or nurse practitioner within 24 hours of admission, and at least twice weekly after that. If the SNF can’t accommodate that, tell them you want to move your mom or dad out to another facility (the SNF is responsible for arranging that). If they still don’t comply, call the state board of health and report them.
SNFs do not have in-house pharmacies, labs, X-rays, oxygen. Your loved one’s medications must be ordered from an outside pharmacy, and may take hours to get to the SNF. If they arrive at the SNF in the evening, they might not get pain medication or antibiotics all night because they missed the evening delivery. If this happens, make sure the nurses call the on-call doctor to get an emergency order called in to the pharmacy for an expedited delivery.
While there are SNFs run by ethical administrators and nursing directors who work hard to deliver excellent rehab and medical care, many are not. Even though SNFs are some of the most regulated businesses in the country, rules are broken and corners are cut for the sake of profit. Our system is disgraceful – but it is what we have. Unfortunately, bringing patients home earlier is just not a viable option for most people, given the expense of hiring private caregivers.
So what can you do about it?
- When your loved one is going to be discharged from the hospital, the social worker/discharge planner is required by law to offer you several choices of SNFs.
- Visit the facilities.
- Look at the way patients are treated.
- Look at the nurses to see if they are happy and healthy, and if you would want them caring for you. If they look stressed and unhappy, maybe its a bad work environment and therefore a bad healing environment.
- Interview the Administrator and Director of Nursing. Do you trust them? Ask them how many physicians come to see patients. How often do they come? What is the name of the physician who is going to care for your loved one? Look at the physician’s reviews.
- Look at the on-line reviews of the facilities.
If you don’t like any of the options, tell the social worker to find other options. Note that social worker/discharge planners in the hospital are pressured by the hospital to get patients out of the hospital (hospital profits go down if beds are occupied by people who are not receiving services) – so they will push back and pressure you to accept their offerings. However, you are not obligated to like the choices offered. They way those choices were determined, by the way, is that the patients are entered into a database and nursing homes bid on the patients if they have empty beds to fill. So, your loved one is treated as a commodity, and nursing homes are offered based on convenience not appropriateness.
Take control. Be in charge of choosing the best SNF for your loved one. Know the SNF administrator’s name and number and call them if you are not happy with your loved one’s care. Get the physician’s name, talk to them, and insist on knowing the visit days and medical plan. Know the therapy plan.
When the patient is in the facility, Medicare requires an Interdisciplinary Team Meeting that includes the patient and family to address questions, discuss the plan, and the projected discharge day. Make sure that meeting is scheduled within 2 weeks of admission. Go to that meeting!
Important Point – Chemotherapy does not happen in SNFs! As I said before, SNFs get a daily rate to care for patients. Cancer treatments often cost more than that daily rate, so it is impossible to give it to patients. It is not uncommon for patients newly diagnosed with cancer to be sent to a SNF to “get strong enough” for chemo. This is a death sentence unless you get involved. Make sure that an appointment with a cancer doctor is arranged, and that arrangements are made for treatment as an outpatient (meaning they leave the facility, get the treatment, and return to the facility). If you don’t do this, your loved one’s cancer diagnosis will be ignored and go untreated until they die.
This is a huge subject, so there will be more about it in future blog posts.