1. 
   

   What are the levels of care provided in skilled nursing facilities?

   
   
2. 
   

   What types of interdisciplinary care services are provided at skilled nursing facilities?

   
   
3. 
   

   What are the roles and responsibilities of hospital and facility providers in ensuring adequate transitions to and from the hospital?

   
   
4. 
   

   What is the future of skilled care after hospital discharge?

With the assistance of hospital interdisciplinary professionals, hospitalists plays an integral role in ensuring timely and efficient discharge planning for a spectrum of patients, including those who require skilled nursing or nursing home care. Having knowledge of both the level of care provided as well as the challenges in care transitions to these settings is imperative.

Skilled nursing facility (SNF) or “subacute” care is provided mostly after an acute hospitalization, and consists of nursing or rehabilitative services that may not be practical on an outpatient basis, like intravenous injections and frequent physical therapy. These facilities are a common site for hospital discharge: 12% of all discharges in 2006 were to “long-term care and other facilities.” Knowing about the types of services provided at SNFs is important for hospital-based physicians, as the scope and intensity of the care their patients will get after they are discharged to these facilities will differ significantly from that which they will have received in the hospital up to that point.

Long-Term vs Subacute Care

There are two major categories of patients in nursing homes: those who reside in the facilities and receive long-term care, and those who are admitted for SNF care, most often following hospitalization. These two groups differ in terms of their clinical features, as well as in the financing sources for their nursing facility stays.

Long-term care is the more traditional service provided in a nursing facility. These “residents,” as they are called, when they stay in a nursing facility for the long term, receive custodial care and help with their Activities of Daily Living (ADLs), and have their medications administered to them by a nurse. Of note, elder caregivers’ most common reasons for seeking placement are difficult-to-manage, dementia-related behaviors, as well as increased functional needs. Long-term care is not reimbursed by Medicare, so as a result, residents have to pay for their stays out-of-pocket, until the cost of their care exceeds their income (“spend down”) to qualify for Medicaid, which does cover long-term nursing facility stays.

Skilled nursing facility care may be provided in freestanding nursing facilities or hospital-based units, though the trend has been toward freestanding community-based facilities. Hospital-based facilities made up only 7% of all SNFs in 2008, compared to 12% in 2000. These units provide services for posthospital stays, mainly for the purpose of rehabilitation, wound care, or other postacute care. Skilled nursing facility care is reimbursed by Medicare and many other private insurance programs, at a higher rate than Medicaid, which may explain the growth in this sector as a percentage of overall services provided at skilled nursing facilities.

Medicare provides coverage of up to 100 days after a medically necessary hospital stay of at least 3 consecutive days. The most common reason for SNF admission in 2006 was rehabilitation after orthopedic surgery, such as total hip replacement. The next most common diagnoses were congestive heart failure and pneumonia. Generally, the main purpose of a SNF stay is rehabilitation or other skilled nursing service (eg, wound care) to ensure the highest possible level of function in order to return to the previous living arrangement in the community. Skilled nursing facility care also differs from that which is provided in the hospital, as detailed in Table 172-1.

Skilled Services

The complexity of SNF care varies greatly throughout the country, from the provision of short-term rehabilitative services to returning long-stay residents to a facility, to more specialized facility programs, such as ventilator weaning. However, there are a core set of skilled services which generally merit reimbursement from Medicare or other payers.

These are

• Rehabilitation: The three main therapy disciplines which perform rehabilitative services at SNFs are physical, occupational, and speech therapy. Generally, therapists work with patients 5 to 7 days per week.
  
  
  
  • Physical therapy: Therapists work with patients on gait, balance, and lower extremity strength and mobility.
    
  • Occupational therapy: Activities include training on performing ADLs, as well as upper-extremity strength training.
    
  • Speech therapy: Diagnoses treated include dysphagia, as well as aphasia, especially in the context of acute or subacute neurologic disease (eg stroke).
  
  
• Wound care performed by nurses at least daily.
  
• Intravenous (IV) therapy: This may include simple IV fluids, as well as medications such as antibiotics.
  
• Provision of feedings in the context of a new percutaneous gastrostomy tube.
  
• Supervision of clinical conditions by nurses or physicians: Examples of this would include frequent laboratory monitoring, skilled nursing observation of congestive heart failure, and renal hemodialysis.

Hospital Team

Understanding predischarge resources available can better ensure the hospitalist can facilitate a successful transition to the nursing home setting. Most hospital settings have a relatively large team of professionals from different disciplines who work together to provide acute care for complex, hospitalized older patients. An understanding of the importance of the team approach as well as an appreciation for other team members’ roles is critical to good geriatric care. Team members that physicians regularly collaborate with include the following:

Therapist

Physical and occupational therapists and speech language pathologists are involved as indicated throughout the hospitalization in order to help determine what level of care and rehabilitation patients will need upon discharge. Indications for consultation of physical therapy include

• Change in functional status such as new loss of range of motion, sensory changes or focal weakness
  
• Altered weight-bearing status
  
• Falling or gait unsteadiness
  
• Need for walkers, canes, or crutches for ambulation or fabricated back braces
  
• Assessment of home discharge plan that may require physical therapy versus transfer to SNF

Indications for occupational therapy consultation include

• New upper-extremity weakness or sensory impairments
  
• Splinting or recommendations for adaptive equipment
  
• Management of edema
  
• Cognitive or safety issues
  
• New visual or perceptual impairments
  
• Impairment of ADLs
  
• Evaluation of home safety