INDIANAPOLIS — Twenty-first-century patients typically don’t stay in the hospital until they are completely well or totally healed. As hospitalization durations decrease, a significant number of older patients — about one in five — are discharged to skilled nursing facilities for continuation or closure of their care.
Deciding on the right post-discharge rehabilitation destination is important to future health and quality of life. However, it is a decision for which many patients and families are unprepared and unsupported, according to scientists from the Indiana University Center for Aging Research.
Choosing a facility that matches the level of the patient’s care needs is difficult. How often does a physician see residents at a particular rehab facility? Can laboratory tests be done urgently, if needed? Patients often have multiple medical problems; is specialized care and equipment provided for such patients?
“I am a primary-care physician,” said the paper’s first author, Arif Nazir, M.D., an IU Center for Aging Research scientist and associate clinical professor of medicine at IU School of Medicine. “If I recommend knee surgery to a patient, I provide recommendations on physicians who I know do the procedure well. I don’t say, ‘You need surgery, so you should go out and find a doctor who operates on knees close to your or your daughter’s home.’ But that’s really what often happens when patients are about to be discharged from hospitals and need to go to a rehab facility for continued care.
“Typically hospitals provide a list of institutions and, because of misinterpretation of government regulations and lack of information on various facilities, don’t give advice. Not knowing what to do and often needing to make a quick decision, the choice is frequently made by the patient and family based on location or physical attractiveness of the facility. But for short-term post-hospital admissions, the facility needs to be selected on how well they can continue the care the patient received in the hospital.”
According to Dr. Nazir, hospitals may over-interpret Social Security Act regulations, enforced by Centers for Medicaid Services. These regulations state that the selection of post-discharge destination is a free choice. This does not, he says, absolve hospitals of the responsibility of providing unbiased assistance in the selection of the most appropriate facility.
The paper, co-authored by Regenstrief Institute investigator Greg Arling, Ph.D., also of the IU Center for Aging Research and IU School of Medicine, and by Milta O. Little, D.O., of Saint Louis University School of Medicine, advocates patient-centered, skilled nursing facility selection taking into consideration such factors as disease severity and prognosis; patient insurance information; and quality of post-hospitalization services offered.
“Not being discharged to the right or right type of nursing home can result in rehospitalization, which is bad for both the patient and the health care system,” said Dr. Arling, a health services researcher who studies health care utilization. “We know that almost one-fourth of Medicare beneficiaries discharged from the hospital to a skilled nursing facility are readmitted to the hospital within 30 days, and we want to get this percentage down.
“Rehospitalization is difficult for any patient and especially older adults. Returning to the hospital puts them at greater risk for delirium, falls and infection.”
“Hospitals are responsible for a safe transition to the next venue where the individual will receive post-acute rehab,” Dr. Nazir said. “The discharge destination discussion needs to begin right away so families have time to visit the facilities.” He also recommends consulting the checklist on the U.S. government website www.medicare.gov/NHCompare before making a placement decision.
Dr. Nazir is past president of the Indiana Society for Post-Acute Long-Term Care Medicine. He currently serves on the board of directors of The Society for Post-Acute and Long-Term Care Medicine, as does paper co-author Dr. Little.
Work on “More Than Just Location: Helping Patients and Families Select an Appropriate Skilled Nursing Facility” was supported by grant 1K01HP20517 from the Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services.
A three-minute video re-enactment depicting what often transpires between the patient and the medical team and between the patient and family before discharge is available on YouTube.
The vignette was developed to help medical students, residents and attending physicians tackle the problem and be prepared to support patients and families in making decisions on continuing care.