By Judith
Graham APRIL 11, 2019
Every
year, nearly 2 million people on Medicare — most of them older adults — go to a
skilled nursing facility to recover after a hospitalization. But choosing the
facility can be daunting, according to an emerging body of research.
Typically,
a nurse or a social worker hands out a list of facilities a day or two —
sometimes hours — before a patient is due to leave. The list generally lacks
such essential information as the services offered or how the facilities
perform on various measures of care quality.
Families
scramble to make calls and, if they can find the time, visit a few places.
Usually they’re not sure what the plan of care is (what will recovery entail?
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
particular facilities and that 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 we leave patients and families without good guidance at a
really vulnerable point in their care trajectory,” said Dr. Robert Burke, an
assistant professor of medicine at the University of Pennsylvania’s Perelman
School of Medicine.
Amid
stress and confusion, older adults and their families frequently make less than
optimal choices. According to a 2018 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 hospital stay could have selected a
higher-rated provider within a 15-mile radius. On average, MedPAC noted,
hospitals refer patients needing short-term rehabilitation to 34 facilities.
(Fewer options are available in rural areas.)
Where
older adults go is important “because the quality 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 they end up going home or to a
nursing home for long-term care, among other factors.
A recently completed series of
reports from the United Hospital Fund in New York City
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 Nursing Home Compare, which rates facilities
by quality of care and other performance criteria, weren’t recommended, easy to
use or especially helpful.
What do
older adults and family members need to know before selecting a rehab facility
after a hospital stay? Recent academic research, policy reports and interviews
with experts elucidate several themes.
The
Basics
Who
needs post-hospital care in a rehabilitation center? Surprisingly, there are no
definitive guidelines for physicians or discharge planners. But older adults
who have 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 for 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 hospital stay of at least three days; and (2)
if an older adult needs physical, occupational or speech/language therapy at
least five days a week or skilled nursing care seven days a week.
Be sure
to check your status, because not all the time you spend in a hospital counts
as an inpatient stay; sometimes, patients are classified as being in “observation care,” which doesn’t count toward
this three-day requirement.
Traditional
Medicare pays the full cost of a semiprivate room and therapy at a skilled
nursing facility for up to 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 may have different cost-sharing requirements.
Nationally,
the average stay for rehabilitation is about 25 days, according to a recent editorial on choosing
post-hospital care in the Journal of the American Geriatrics Society.
Quality
Varies Widely
In its
2018 report, MedPAC documented large
variations in the quality of care provided by SNFs. Notably, facilities with
the worst performance were twice as likely to readmit patients to the hospital
as those with the best performance. (Readmissions put patients at risk of a
host of complications. This measure applied only to readmissions deemed
potentially avoidable.) Patients at the best-performing facilities were much
more likely to be discharged back home and to regain the ability to move around
than those at the worst-performing facilities.
In
April, for the first time, Medicare’s Nursing Home Compare website is
separating out performance measures for short-term stays in SNFs, for people
who are recovering after a hospitalization, and long-term stays, for people
with severe, chronic, debilitating conditions.
Seven
measures for short-term stays will be included: the portion of patients who
experience an improvement in their functioning (such as the ability to walk),
return home to the community, are readmitted to the hospital, visit the
emergency room, get new prescriptions for antipsychotic medications, have pain
well controlled, and 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 homes and assisted
living centers. There will also be a separate “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 family members 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 during
the post-hospital period? What kind of help will be needed, and for
approximately how long?
Dr.
Lena Chen, an associate professor of internal medicine at the University of
Michigan who 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 might be?
What
the SNF provides. Bowles also suggests people ask why the SNF is being
recommended instead of home health care. How will the SNF meet my needs,
specifically? What kind of medical care and therapy will I get there? From whom
and how often?
Carol
Levine, who directs the United Hospital Fund’s Families and Health Care
Project, suggests that patients and families seek out details about facilities.
Is a doctor readily available? (New research suggests
10% of patients in skilled nursing facilities are never seen by a physician,
nurse practitioner or physician assistant.) What kind of equipment and
specialized services are on-site? Can the facility accommodate people with
cognitive issues or who need dialysis, for instance?
Getting
information early. Dr. Vincent Mor, professor of health services, policy and
practice at Brown University’s School of Public Health, said patients and
families should insist on seeing a discharge planner soon after entering the
hospital and start the planning process early. When a planner comes by, “say,
‘I don’t care about choices: Tell me, what do you think will 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 has written about. He suggests that older adults
or their families insist they be given time to contact facilities if they feel
rushed. While there’s considerable pressure to discharge patients quickly,
there’s also a requirement that hospital discharges be safe, Burke noted. “If
we’re waiting for a family to tell us which facility they want a patient to go
to, we can’t make a referral or discharge the patient,” he said.
Judith
Graham: @judith_graham
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