Making It Work: The Challenging World of Skilled Nursing Homes

Making It Work: The Challenging World of Skilled Nursing Homes

by Bunni Dybnis, MA, MFT, CMC

I receive calls on a regular basis from individuals concerned with aging, ill or dependent adults. They want to find the best nursing home.     The callers typically will request options from long list of skilled nursing options given to them by a hospital discharge planner.   These decisions need immediate attention.   For others the calls vary from concerns regarding financial issues, medical necessity or other long term planning situations.  Like is often the case, one size doesn’t fit all.  Setting realistic expectations is essential.  Nursing Home often becomes the generic term for someone in search of facility placement.  Nursing homes certainly have their place, but they are not right for everyone.  Whether it is from lack of knowledge, a medical and reimbursement bias, lack of time or misinformation ,other options are often not considered.  Aging Life Care Professionals® provide knowledge that goes beyond a simple list with the nursing homes. 

Aging Life Care Managers focus on understanding goals, needs, obstacles and finding solutions.  Understanding why skilled nursing is the recommendation is essential.  An assessment by a skilled Aging Life Care Manager can be invaluable.

Let’s start with goals:

  • Situation #1: Hospital Discharge

“My family member is about to be discharged from the hospital and the doctor says they need a nursing home.  I was given a list and need to know the best place. “

Rehabilitation after a hospitalization is a common process.  Following a hospital admission a skilled need nursing home placement is often a short term solution.   Rehabilitation following a stroke, hip replacement or other skilled needs often makes this choice a reimbursable event which can support an individual’s move to a less restrictive environment.  When situation involves brain injuries and other neurological issues there are specialized care facilities that might be available.   These individuals can benefit from the skills of a multi-disciplinary team of trained therapists and nursing staff.  Therapy is often provided several times a day.   If hospital discharge is a qualifying event commonly three weeks and sometimes up to 100 days can be reimbursable, at least in part, by insurance. On-going reviews by facilities occur to maintain eligibility. Skilled nursing is reimbursed at the highest level, by Medicare and private insurance companies, so skilled nursing often compete for these clients and choices can be robust.  If a patient has an HMO or on MediCal/Medicaid, options are smaller.

Alternative solution- For many going home for rehabilitation is their preference.   Risk of infections, institutional related confusion and the often depressing environment are a consideration.  With doctors’ orders skilled occupational, physical and other services can come to the home for a set amount of visits.  These services can be reimbursed by Medicare and other insurance carriers.   The need for custodial care done by family, friends or paid caregivers can support the therapists.   Cost and caregiver burden must be considered. 

  • Situation #2 : Skilled needs that necessitate move from assisted living or home

My father has a feeding tube and is not able to assist with transfers of any kind. The assisted living tells me they can no longer care for him.  Private skilled nurses are unaffordable, so he can’t be taken home.  What are the options?

Long term stays when skilled needs are present are another reason for skilled nursing placement.  For these individuals nursing homes can be the best option.    These admissions generally relate to tasks that can only be provided by a Registered or Licensed Vocational Nurse or require the skills and necessity of more than one person to transfer.  Feeding tubes, catheters, ventilators, and medical situations often necessitate long term stays. Costs, insurance reimbursement, physical demands on family caregivers and licensing all play into this. If an individual will eventually run out of assets, then MediCal/Medicaid Certification is an important consideration when looking for placement. If a skilled nursing facility is a long term consideration an Elder law attorney or community legal aid should be consulted earlier than later.

Alternative solutions- In many states there are Assisted Living Waiver programs that provide all the care available in a Skilled Nursing Home in more home like life assisted living facility.  Availability is limited and priority is given to those already in Nursing Homes so it is important to be proactive.  Hospice waivers and some assisted livings who have licensed staff can provide skilled care that formerly was only provided by nursing homes.  It is important not to just assume nursing homes are the only options for long term care.  For individuals who do not have skilled needs and are paying out of pocket or through long term care insurance an assisted living may be a preferable cost effective options.

  • Situation #3- Lack of resources to address care needs

“My parent needs around the clock assistance. We cannot take care of her or afford to pay for services needed.  She has very limited resources.   Where can we place her?”

Skilled Nursing is the safety net for the indigent individuals who require long term care. Individuals who meet functional and financial criteria are often placed in nursing homes as a last resort.  The medical model of shared rooms with a nursing staff at a front desk, which is the only option available in many communities are often in contradiction with emotional, social and cognitive needs.  Throughout the country, MediCal beds in nursing homes are where most impoverish older adults will spend their final days.

Alternative solutions- The nurturing supervised environments that would best serve the emotional as well as physical needs of individuals is for a lucky few available in waiver programs, but these are limited in number and location.  Specific criteria for MediCal/Medicaid long term care is needed.   If criteria is met without the need to spend down or protect assets the facility will often assist with application.   If there is any questions or sophisticated planning is needed an Elderlaw attorney should be contacted.  An Aging Life Care Manager, knowledgeable in this field, can often guide you to less restrictive options.  In-home supportive services and Veterans assistance can also provide resources for those who chose to stay home.

There are many check lists available to assist individuals looking for skilled nursing for themselves a loved one or client.  Rather that reproducing an exhaustive list I will review a few important considerations and priorities that need to be evaluated.

  • What is the need? Short term placement with the goal of rehabilitating or recovery from a hospital stay as opposed to long term skilled or financial needs will greatly affect choices
  • How critical are the care needs? For those with complicated rehabilitation and breathing needs finding the top rated rehabilitation or sub-acute services may trump other criteria such as location, esthetics or proximity to personal medical team.  Insurance coverage always remains an important consideration for most.
  • What are the family and patients priorities? People are different and what they desire must be evaluated case by case.  When I ask families what they mean my “best choice” I often get differing responses.  Here are a few:
    • Financial coverage by insurance or long term MediCal remains the number one priority for most. It is essential to check admission status and reimbursement, particularly following hospital discharge and Medicaid/ MediCal coverage.  If an individual needs to move from Medicare reimbursement to Long Term MediCal a facility has to be licensed to cover those expenses. It is essential to understand regulations and rights concerning these issues.  org is a great resource.
    • Personal doctor or medical team will visit remains a consideration for some.
    • Close proximity to social network. Having regular visits from family and friends can make all the difference
    • Physically esthetic. For many the “bricks and mortar” is an important consideration.  Remember, as enticing as it might be, “you can’t always tell a book by its cover”.
    • Private rooms available at an extra cost. If an individual is sensitive to noises or other situations where having a roommate may be distressing there is a cost involved.  Patients with contagious infections need to be isolated by law.  This can make finding the facility of first choice a challenge.
    • Ideal nursing and other care services are not a given. Families need to understand regulations regarding staffing ration are about 9 patients to 1 staff. This assumes the facility is fully staffed.  If patient needs individualized care or attention it is not realistic to assume facility staff will meet those needs.  Unless there is family participation or additional private caregivers to advocate or provide oversight expectations much be managed.
    • Ratings in terms of violations, licensing and deficiencies. Information is available on Medicare.gov.  Unless violations are continuous and/or egregious checking current situation is recommended.  Not all is as it appears.
    • Social and other considerations for long term care residents. If an individual is placed for short stay rehabilitation or recuperation having activities beyond medical and care is probably not an issues.  For longer stays activity programs, volunteers, outside patios and other quality of life considerations need to be considered.

I know we all want a quick easy answer to our questions, but like most other important issues making decisions regarding care for an aging or dependent adults is not that simple.  Understanding the options, needs and challenges is the first step in making the right choices.  Aging Life Care Managers are equipped with the training, knowledge, experience and objectivity to support decisions involving older adults and their families.


About the Author: Bunni Dybnis, MA, LMFT, CMC has spent the last twenty-five years working exclusively with older and dependent adults as an Aging Life Care Manager,  educator, consultant , expert witness and mediator. As Director of Professional Services at LivHOME and Fellow in the Aging Lifecare Association she has received numerous awards and acknowledgement from her peers and greater community.

This blog is for informational purposes only and does not constitute, nor is it intended to be a substitute for, professional advice, diagnosis, or treatment. Information on this blog does not necessarily reflect official positions of the Aging Life Care Association® and is provided “as is” without warranty. Always consult with a qualified professional with any particular questions you may have regarding your or a family member’s needs.

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