We find that many families’ first experience with Senior Living comes after a hospitalization and that families don’t know what their options are, or what to expect on this initial part of the journey. Here we’ll discuss where Seniors go for Medicare-funded rehabilitation after a hospitalization. You will also learn some strategy tips, and some warnings about aggravating things to watch out for when dealing with Post-Hospitalization Rehab. If you prefer a video covering this topic, you can watch it here.
With a three-night hospital stay, a Senior automatically qualifies for a rehabilitation stay paid for by Medicare. The five most common reasons Seniors go to rehab are for urinary tract infections, pneumonia, hip replacement, sepsis, or a stroke. What is the goal of a rehabilitation stay? To get stronger in a safe environment. The reason Medicare pays for rehabilitation is economic. It costs less to pay for rehab than it does to risk a Senior having to go back to the hospital for a fall when the Senior may not have recovered sufficiently from a hospitalization.
A family has two in-patient rehab options for a Senior coming out of the hospital: a rehabilitation hospital or a Skilled Nursing facility. The key difference between these two options you need to understand is this: Rehabilitation Hospitals make you work twice as hard but keep you for about half as long compared to a Skilled Nursing facility.
Rehabilitation Hospitals are always my preferred choice for a rehab stay. This is because they are uniformly nicer. They are usually newer, more attractive, and less chaotic than a Skilled Nursing home. A patient always gets a private room and has more interaction with the nurses, and generally, the care seems much better. In the Austin area, there are seven free-standing rehabilitation hospitals that average 54 beds, and four hospitals that have rehabilitation units, three of which are quite small.
The most important thing to know about a Rehabilitation Hospital is that a patient must be able to handle fifteen hours of rehabilitation a week, as much as three hours per day. This may not sound like a lot, but for a Senior coming out of a hospitalization, it is a difficult hurdle, and most Seniors can’t handle so much physical exertion. Instead, they go to nursing homes, which perform half the daily amount of rehab. You should count on a rehab hospital stay generally being about ten days, though the average stay is twenty days.
A rehabilitation hospital stay is covered under Medicare Part A, which covers hospitalization and which has fewer co-pays and fewer limits. So going to a Rehab Hospital is sometimes a savvy strategy to save Skilled Nursing eligibility for a possible later time, and to minimize out-of-pocket expenses.
It is sometimes possible to transfer from a Rehabilitation Hospital to a Skilled Nursing facility. This usually happens when a patient can’t meet the three hours per day rehab requirement or is denied a longer stay for some other reason. If a patient would still benefit from a less strenuous rehabilitation regimen and has some medical need, Medicare will sometimes agree to pay for a Skilled Nursing stay. But when this happens, Medicare will lower its payment to the Rehabilitation Hospital, under the concept that the Rehabilitation Hospital needs a financial incentive to discharge the patient back home. Therefore, the Rehabilitation Hospital will often not tell the patient’s family of the option to go to Skilled Nursing, or otherwise try and talk them out of the idea.
Skilled Nursing Facilities
As mentioned, most Seniors go to a Skilled Nursing facility for rehabilitation, because the Senior can’t handle as much work as a Rehab Hospital requires, and may benefit from a longer recuperation stay in a supervised environment. Skilled Nursing homes are larger, averaging about 110 beds in the 51 homes in the Austin region. Usually, you get a shared room, but about half of Skilled Nursing facilities have private rooms for Medicare patients.
Just under 80% of the population are long-term residents who aren’t receiving rehabilitation services. So a Skilled Nursing has a different feel, a different vibe, and Rehab patients feel more like outsiders during their brief stay. Patients in Skilled Nursing get seven and a half hours of rehab per week, and rarely on weekends. Everyone likes their rehabilitation professionals because they are positive, encouraging, and kind. Most of the rest of the Skilled Nursing experience is mediocre at best, and sometimes downright dehumanizing.
Skilled Nursing stays are covered under Medicare Part B, you get up to 100 days of Skilled Nursing per year, but this can be misleading for two reasons. Number one, only the first twenty days are paid for entirely, while there is a $185 per day co-pay for the second 80 days. Number two, Medicare only pays for the time when a patient is making progress in his rehab. Once the progress stops and the rehab stay isn’t making the patient any stronger, he is said to have “plateaued,” and Medicare will no longer pay for him to stay.
I usually see rehab patients stay about 21 days in a Skilled Nursing home when they are only there for rehab. Nationwide, the average Medicare stay in a Skilled Nursing home is somewhere above 35 days, but this is longer when there are unstable patients who require nursing care and whose stay in the hospital is prolonged for reasons other than rehabilitation services.
Home-Health Rehabilitation Services
Home Health is a standard part of the rehabilitation plan after patients discharge from either a Rehabilitation Hospital or a Skilled Nursing facility. Medicare almost always pays for rehab to follow a patient home for twice-a-week visits for about six weeks. But Home Health is also a rehabilitation option for folks who don’t want inpatient stay. This is usually younger, healthier patients who have not deteriorated much during their hospitalization.
Dementia and Rehab
Let’s discuss dementia and in-patient rehab for a moment. I sometimes recommend to families of Seniors with dementia to consider skipping Skilled Nursing and instead do rehab at home, or even at their Memory Care community. This may require hiring a personal trainer to supplement the work done with Home Health. A privately paid personal trainer costs about $75 per session. The problem for dementia sufferers is they may have a hard time accepting a new environment, and their cognition is more impaired after the event that sent them to the hospital in the first place.
Remember, the point of inpatient rehabilitation is to get stronger in a safe environment. Home – wherever that is – may be safer than a Skilled Nursing. Dementia sufferers may forget they are still injured or weak and may try to walk in their diminished state, resulting in another fall. Dementia sufferers may become more confused and uncharacteristically wander about and get into trouble. They may not get enough supervision in the dining room, and consequently, lose weight from not being cued to eat. Lots of things can happen, so sometimes for those with dementia, a more familiar environment is a preferable option.
Downside to In-Patient Rehab
There can be downside in Skilled Nursing for non-dementia patients as well. Infections are all too common in in-patient rehabilitation settings. Even before the pandemic, infections such as c-diff, pneumonia, and urinary tract infections were more common than at home. This happens both because a patient is in a weakened state, and also because they are exposed to other patients recovering from illnesses. Skilled Nursing homes are notorious for being understaffed, and care is not always up to standard.
Therefore, families should be cautious about using a Skilled Nursing stay as a Respite Stay because negative outcomes do happen. Everyone in the Senior Care community has stories about someone going into rehab just because they qualify, and thinking a rehab stay would be nothing but a tune-up. And then something bad happens. So think twice before overstaying in a Skilled Nursing home.
Tips to Know
Here are several things to keep in mind before a rehab stay.
- Since we are talking about a short-term stay, location is not as critical, though of course desirable. It is more important to go to a good rehab facility than it is to be close.
- Insurance sometimes dictates where you can go on Medicare. Traditional Medicare is almost. universally accepted at an inpatient rehab. Medicare Advantage plans seem worse overall, and may not be accepted by many inpatient rehab facilities, and seem to approve stays only about half as long as traditional Medicare plans.
- You can negotiate some on your discharge date. Usually, Skilled Nursing Homes. can finagle two or three extra days for a family who isn’t quite prepared to take their loved one home. But it is also possible, and not extremely expensive, for the family to pay privately for a nursing home room for a few days while a family prepares the next step. I usually see this scenario when a family is scrambling to coordinate a discharge into an Assisted Living or other community. It is also possible to appeal the discharge date to Medicare and argue for a longer rehab stay. This is not always successful, of course, but families need to be aware of this option.
You need to make friends and keep in close contact with the social worker. They are also sometimes called the discharge planner or case manager. This professional is the primary point of contact for the family at the facility. Ideally, from the family’s perspective, the social worker should be performing three jobs:
- Coordinating the patient’s care and well-being while in the facility
- Preparing the resources for the patient to discharge successfully from the facility
- To be in close communication with the family as to the patient’s progress and needs
What this means, again in the ideal scenario, is that the social worker will coordinate weekly care plan meetings for each patient with the interdisciplinary team of rehab professionals, nurses, dieticians, and activities director. Families have the right to attend these meetings, by the way. Then the social worker will communicate the information with the family, and prepare the family for the discharge with the necessary resources, such as durable medical equipment, information on where the patient should live going forward, details on Home Health rehab, and other solid advice and resources.
In reality, the social workers are so burdened with other jobs as well that they can rarely serve these functions as well as they would like. Consequently, all too often, the first time the family hears from the social worker is when they are being told the discharge date, and the family is not given enough support.
To avoid this, the family needs to introduce themselves to the social worker immediately and must be a squeaky wheel in their role as an advocate for their family member. This may mean phone calls, emails, and texts, and not giving up when replies are few and far between. Good communication with the social worker is essential.
Here are seven pet peeves about what we see in nursing homes, much of which is the result of understaffing and poor leadership.
- Nursing homes overuse diapers to make life easier on staff, because staff is overworked and often doesn’t have time to take patients to the bathroom.
- Often staff uses wheelchairs to take patients to the rehab gym, instead of helping them walk and getting exercise. This is easier and quicker for staff, with less chance of a fall.
- Sometimes you see diabetics who use pills at home but who are getting sliding scale shots instead in the nursing home. This happens because nursing homes can get paid extra for this service, but it makes for a lot of confusion upon discharge.
- Medications are often changed either in the hospital or in the nursing homes, without adequate information being given to the family. Prescription checks must always be done with the family doctor immediately upon discharge.
- Patients are frequently discharged without adequate warning or consultation with the family.
- Patients are frequently discharged without being given their prescriptions, requiring the family to scramble to avoid gaps in medication dosage.
- Patients are frequently discharged on Friday afternoons, when families have no time to get to stores for supplies, or when senior living facilities don’t have the staff to properly attend to a new resident.
Now we’ve focused a lot on the downsides to inpatient rehab because warnings are partially the topic of this discussion. But it must be noted that for the vast majority of rehab patients, the process goes smoothly and effectively. I’m not trying to talk anyone out of an inpatient rehabilitation stay. This discussion falls into the category of the old saying of “Trust But Verify.” All rehabilitation patients need outside support and advocacy in order to achieve maximum success.
We hope this discussion has provided you food for thought when considering your options for post-hospitalization rehabilitation services. As ever, if you’re considering a move to Assisted Living, Independent Living, or Memory Care in the Austin, Texas area, please call Michael Gill at 512-630-7133.