Skilled nursing facilities, also known as rehabilitation facilities, are frequently used as a transition from a hospital stay to either going back home or to assisted living.
Jump ahead to these sections:
- What is a Skilled Nursing Facility?
- What’s the Difference Between a Skilled Nursing Facility and a Nursing Home?
- How Do Skilled Nursing Facilities Typically Work?
- How Can a Loved One Pay for Care at a Skilled Nursing Facility?
- How Do You Know If a Loved One Is Ready For a Skilled Nursing Facility?
- Pros and Cons of Skilled Nursing Facility
- Tips for Choosing the Best Skilled Nursing Facility
- Top Questions to Ask a Skilled Nursing Facility Before You Commit
Because rehabilitation is only covered by Medicare after a three-night stay in the hospital, families face tough decisions if these criteria are not met. If Medicare is not a part of the equation, it can still be hard to choose a skilled nursing facility, and what criteria people should have in mind when selecting a skilled nursing facility.
Some families can be caught unaware when asked to choose a skilled nursing facility, often with very little time.
They might be asking: How do skilled nursing facilities differ from other types of short-term care? Why would some people select skilled nursing facilities? Why do I need one? Does this mean my loved one is going to a nursing home?
What is a Skilled Nursing Facility?
The term skilled nursing facility is often used interchangeably with nursing home care. The two types of care are defined by the following:
- Inpatient rehabilitation. Inpatient rehabilitation is a short-term stay following hospitalization for an accident, injury, or illness. The length of stay is determined by the medical condition and the insurance criteria for coverage. The typical services provided are primarily physical, occupational, and speech therapy. Nurses are available 24 hours a day and a physician manages care while the patient is receiving these services. Once the patient has stabilized or is no longer making progress, they are discharged home. If the patient has not recovered to the extent that they can safely return home, long-term care in a nursing home may be recommended.
- Long-term care nursing home. Long term care in a skilled nursing facility refers to permanent placement and stay in a nursing home. For someone to be in a nursing home means that they don’t need a hospital, but can’t be cared for at home. Nursing homes have 24-hour nursing and aide service.
For this article, we focus on skilled short term rehabilitation skilled nursing facilities.
What’s the Difference Between a Skilled Nursing Facility and a Nursing Home?
There are significant differences between a skilled nursing facility and a nursing home, although the terms are used interchangeably, leading to confusion. Let’s sort out the differences.
Skilled nursing home
Skilled nursing is short-term rehabilitation following an accident or illness. Insurance coverage for skilled nursing varies depending on the plan you have. Some plans have co-pays, and others do not. The length of stay is determined by the therapy staff who evaluate your progress towards goals and the insurance company’s requirements for continued stay.
Everyone is eventually discharged from skilled nursing either back home to assisted living or a nursing home. The goal is to help the patient reach the highest level of functioning they can achieve.
A nursing home is a long-term setting for people who need full assistance in all areas of their life. Due to the high cost of nursing homes, most people qualify for Medicaid to pay for the entire cost of nursing home care.
Unlike skilled nursing facilities, nursing homes will not have the sophisticated therapy equipment and staff to provide a high level of therapy services. The assumption is that the person is at a point where aggressive therapy will no longer significantly impact their ability to function independently. Therefore the emphasis is on 24/7 care from nurses and aides to keep someone safe and comfortable.
How Do Skilled Nursing Facilities Typically Work?
As the population ages and people live longer, there is an increasing need for skilled nursing. Chronic and acute medical conditions, falls, and surgeries have led to an increased need for rehabilitation so that people can be discharged back home. Even elective surgeries such as knee and hip replacements are becoming more prominent as well.
Unsure how this fits in with aging care? Here’s a typical scenario: Let’s say someone has a fall and breaks a hip. They need a hip replacement surgery and subsequently need to stay three nights in the hospital. The discharge planner recommends that the patient goes to a skilled nursing facility to recuperate and recover from the surgery. A doctor writes the order and the patient is admitted to a skilled nursing facility that is contracted with their insurance.
Medicare requires a three-night stay in the hospital for the following skilled nursing services to be covered by insurance. In other words, if your loved one is already in assisted living and requires more care than what the community can provide, that will not meet Medicare’s criteria for admission to a skilled nursing facility.
If you have Original Medicare with a secondary insurance plan, you may be entitled to up to 100 days of rehab. With a Medicare Advantage plan, there may also be some co-pays after a certain number of days. Not every Medicare-certified facility will accept some Medicare Advantage plans.
How Can a Loved One Pay for Care at a Skilled Nursing Facility?
Most people pay for care at a skilled nursing facility through their insurance when they meet the qualifying criteria. It is rare, but in some cases, if a loved one does not qualify through insurance, then the patient or family will pay privately. Since skilled nursing is expensive, insurance companies have strict criteria for admission and continue to qualify for services. If your loved one does not make progress or refuses therapies, insurance may dictate an early discharge.
Private pay costs will vary widely depending upon the state you live in and the facility. However, costs can easily run hundreds of dollars a day.
Original Medicare will pay the full costs of skilled nursing home care for the first 20 days, and then there is a co-pay of $185.00 a day up to 100 days. However, most people have a Medigap plan that will cover part of the total cost of the co-pay. So after 100 days, Medicare pays nothing.
Medicare Advantage plans
Medicare Advantage plans, unlike original Medicare, will differ on what they cover depending on the type of plan. Some plans will cover the first 20 days, like traditional Medicare, but then the patient has a co-pay up to a certain number of days. So that there aren’t any surprises, it is best to talk with your insurance company to confirm coverage.
Some Medicare Advantage plans don’t require a three-night stay in the hospital to qualify for skilled nursing. Just like with traditional Medicare, Medicare Advantage plans stop paying after 100 days.
Many employer-sponsored plans offer some coverage of skilled nursing. Again it is best to confirm coverage amount and length of time and if there are any co-pays.
Medicaid is the public health insurance program for people who are low income. Medicaid will pay for skilled nursing if the recipient meets the admission criteria and the facility is Medicaid certified.
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How Do You Know If a Loved One Is Ready For a Skilled Nursing Facility?
Most people rely on the healthcare facility’s medical staff to make recommendations regarding a skilled nursing facility. Most hospitals also tend to discharge people quicker. You may feel alarmed that your loved one is being recommended for discharge from the hospital when it seems as though they aren’t ready. Skilled nursing facilities, however, are experienced in handling complex needs.
It makes a difference if someone plans to go home or to assisted living after hospitalization. Assisted living has a level of support that their home may not have. Assisted living communities provide meals and transportation, have aides, and dispense medications—all of which offer a layer of support.
If you’re not sure if your loved one needs additional care, here are some indications that your loved one may be ready for a skilled nursing facility:
If returning to assisted living:
- They are unable to move or transfer without two people to assist.
- They have difficulty toileting safely.
- They need assistance with eating because of swallowing concerns and safety.
- They may have problems with mobility that make it unsafe for them to walk without standby assistance at all times.
- They may have urinary incontinence that requires short-term catheter care.
- The need for 24-hour nursing care to check vital signs, check on their wound care, injections, or IV medications.
If returning home:
- They may not be able to cook due to physical or cognitive problems.
- They need help with walking, toileting, and getting in and out of bed.
- They require assistance with bathing, dressing, and other hygiene tasks.
- They may have some specific nursing care needs that can’t be covered by a home health nurse.
Pros and Cons of Skilled Nursing Facility
Going to a skilled nursing facility would seem like a given. It can buy time for a family to arrange for more care at home and provides a safe environment for recovery. But, it is not perfect. As with any choice, there are pros and cons.
- Much more therapy. It is not unusual for someone to receive physical therapy (PT) and/or occupational therapy (OT) twice a day (except on weekends) in a skilled nursing facility. However, Medicare reimbursement rules do change, so you may want to find out how much physical and occupational therapy your loved one can expect to receive and what the ratio is for group to individual therapy. Speech and respiratory therapy are also available for people who need it.
- 24-hour nursing. If your loved one needs nursing in the middle of the night, it is available. If someone opts to go home with home health care, nursing is usually scheduled only three times a week with rare exceptions.
- Two-person assist. If your loved one needs two people for assistance and transfers, aides will provide this. Most assisted living communities do not have the staff to provide two people to assist someone.
- Nutrition services. Special and modified diets are standard. If swallowing is a concern, the staff is available for one on one assistance.
- Coordination of medical services. A good skilled nursing facility will coordinate and manage medical services. These may include but are not limited to X-rays, follow up surgeon appointments and communication with the primary care physician. The social worker can arrange for home health and other follow up appointments before discharge home.
- It isn’t home. People are often reluctant to go to skilled nursing facilities because they want to be home. The comfort and familiarity of home are very appealing.
- Cost. Many Medicare Advantage plans will only pay up to 20 days, and then there is a daily copay up until a certain point. Some people can’t safely go home in 20 days and the copay may be a real financial burden.
- Visitor restrictions. Many skilled nursing facilities are also restricting family visits due to COVID-19. This can make it extremely challenging on both an advocacy and social level.
- Dementia may be challenging. If your loved one has memory loss due to dementia, rehabilitation may be difficult. The limitations presented by cognitive impairment may impede the physical progress necessary to recover.
Tips for Choosing the Best Skilled Nursing Facility
The proliferation of skilled nursing facilities has made it both difficult but also easier to try and choose the best one. If you live in a metropolitan area, you may have many to choose from.
In some cases your insurance dictates and narrows your choices, but you could potentially choose from any contracted Medicare facility if you have original Medicare with a secondary policy.
Here are some additional tips to keep in mind when looking at skilled nursing facilities.
1. Visit the facility if possible
If at all possible, visit several recommended skilled nursing facilities. Pay particular attention to cleanliness and the rehabilitation “gym.”
Observe the equipment: is it old or newer? Pay attention to the atmosphere. Does the staff seem friendly and engaging? Do the patients appear to be active and happy?
2. Ask questions
Meet with the director of nursing and therapy services. It is recommended that you ask about team meetings.
How often do they occur and can you attend or call in to participate? When and what times are therapy visits scheduled? How is progress determined? Is family participation encouraged? If there is a concern with care or any other issue, who is the best person to go to with that complaint?
3. Check with the ombudsman
Complaints about care, communication, and other issues tend to go to the ombudsman if they can’t be resolved at the facility level. If a rehab has multiple complaints, this might be a red flag.
Talking with the ombudsman might give you detailed information about a facility under consideration.
4. Recommendations from health providers
Recommendations from health providers don’t always work, but it is worth exploring. Sometimes discharge planners and physicians have their favorite places that may not necessarily reflect good care.
Asking specific questions about why they recommend a particular place can help. If you have a good relationship with a home health company, they too can be a good source of information, since they may be providing services to many patients after discharge from rehabilitation.
5. Talk to friends and family
Personal experience can often be the best recommendation.
You might be surprised at how many people have been through skilled nursing rehabilitation once you ask. Find out what they liked most and what they liked least.
Top Questions to Ask a Skilled Nursing Facility Before You Commit
If you have original Medicare and a Medigap plan, you might have many choices of skilled nursing homes to choose from. However, if you have a Medicare Advantage plan, your options might be more limited. When you are in the hospital, the discharge planner will help you choose a skilled nursing facility, but if you can, ask questions before deciding. If you can’t ask the questions, look to a family member to investigate options with the following questions in mind.
Q: Do you take my insurance?
The discharge planner at the hospital and the admissions coordinator at the skilled nursing home will verify your insurance coverage. But, you will want to make sure that they inform you of any co-pays. Co-pays can add up, and you may not be able to afford them.
Q: What are your inspection ratings?
Better yet, find these ratings yourself before committing. The 5-star Medicare ratings have come under scrutiny because nursing homes can game the system, skewing the results. A more reliable reporting on nursing home deficiencies is through ProPublica. Review inspection reports, fines, and deficiencies.
Q: Is there a registered nurse available 24/7?
If there is a medical emergency, you will want an RN available to assess your loved one’s condition. Avoiding an urgent care or emergency room visit is preferable, and even in cases that aren’t urgent, having a full-time nurse available can give you peace of mind.
Q: Will I have a private room?
A private room, if available, is preferable because you will get more rest and have more privacy. Most good skilled nursing homes offer private rooms, but you will want to make sure.
Q: What is the rehab schedule?
By maximizing your rehab while in a skilled nursing home will help you recover more quickly. Most skilled nursing facilities offer 5-6 days of rehab- sometimes twice a day to accommodate both physical and occupational therapy. But, Medicare guidelines change, so ask what you can expect.
Q: How do you determine progress?
Showing progress is necessary for your insurance to continue paying. Therefore, it is reasonable to ask how progress is determined so you can work towards goals. Also, ask what the average length of stay is for the condition that brought you to rehab.
Q: How do you decide when it is time for discharge?
The last thing you and your family need is to find out suddenly that you are being discharged and don’t have time to put a plan in place. Being discharged does not mean that your loved one is recovered and no longer needs help. In most cases, you will need some kind of support once you get home. Having adequate time to set that up is helpful.
Skilled Nursing Facilities Explained
Skilled nursing facilities are an important and vital piece of the healthcare system. The bottom line is that in most cases they offer the opportunity to more quickly recover from an accident or illness before returning home.
Choosing a good skilled nursing facility can ensure that you and your loved one can be confident in a sustained recovery.