A friend asked me for urgent advice on what nursing home to take her mother, who was being discharged from the hospital soon.
This was nearly 10 years ago, and at the time I was regularly reviewing nursing homes inspections in a special section of The News-Sentinel. I also reported such things as how long the director of nursing had worked at each facility, bed vacancy history and how often facilities changed their names. Poor performing facilities sometimes change names to present a new public persona. The reports examined and compared many other “red”- and “green”-flag issues.
I gave the friend recent reports, suggesting to her, as I did to others who inquired about nursing homes, to read them to form her own conclusion. The next day the friend said she felt panicked and told the hospital to move her mom to a facility closest to her own house. When she named the place, my heart sank. I said, “ 'Visit often.' ”
Choosing a nursing home is daunting and often done in 48 hours or less. Dr. Arif(cq) Nazir(cq), lead author of “More Than Just Location: Helping Patients and Families Select an Appropriate Skilled Nursing Facility,” said most people choose a facility based on location. Hospital stays have significantly shortened. It is not unusual for a patient entering a nursing home to have complex medical needs such as pneumonia, surgical wounds or blood clots, have multiple therapy needs and taking many medications.
“The nursing homes today are the hospitals of yesterday,” said Nazir, associate professor of clinical medicine in geriatrics at IU School of Medicine in Indianapolis. Despite this reality, “There've been no changes in (nursing home) regulations since 1980. The regulations haven't changed. The way we choose nursing homes hasn't changed. The resources behind the way we choose a nursing home have not changed.”
Hospital patients are seen daily or multiple times a day by a hospitalist or specialist. Federal nursing home regulations require minimally a monthly physician visit. Thus it behooves families to inquire with facilities what assurances they have their loved one's medical needs will be adequately met. When care declines, patients end up back at the hospital, Nazir cautions. Nearly one in four Medicare beneficiaries who are discharged from a hospital to a skilled-level nursing home are readmitted to the hospital within 30 days.
“We all know if patients start going through this revolving door of care they start having serious decline,” Nazir said. It's a problem for hospitals too. While insurers demand hospitals move patients out quickly, hospitals are dinged financially if Medicare patients with certain diagnoses come back too soon.
Hospital case managers, in their role of discharge planners, are a key link to helping people choose a nursing home. Dawn Ropp oversees an average of 180-225 patients a month discharged from Lutheran Hospital to nursing homes.
She concurs with Nazir that too few patients and families have done their homework on nursing homes prior to needing one and too often location is the deciding factor. Federal regulations state hospitals cannot direct patients to particular facilities and must guarantee patients have “free choice.”
With more medically complex patients transitioning to nursing homes, Ropp and her staff are increasingly challenged to do as much education as possible in a very short time.
“We ask them to go to the (Medicare.gov) Nursing Home Compare Website,” which rates nursing homes on key factors, including staffing, health inspections and quality measures. Patients are given a list of facilities and their locations. Insurance coverage must be considered. For example, people with certain Medicare Advantage plans may not have as many options in this region compared to those with traditional Medicare supplemental plans.
Another caveat: a patient must be admitted for three midnights in the hospital before Medicare will cover nursing home care after discharge. Some patients are hospitalized initially under observation status which is not admittance. Even then, nursing home Medicare coverage is for a 100-day maximum, and few patients get that many days covered. After Medicare runs out, patients pay out of pocket, go on Medicaid if they qualify or get some help through VA or other long-term care insurance.
Still, sometimes patients insist on going to a place based on location, Robb said, even if the facility has lower-than-average staffing levels or a history of other problems. In the end, it's the patient's choice. The goal for most everyone is that the nursing home be a step toward returning home, Ropp added, but if the patient's medical condition declines, discharge to home is delayed and sometimes never occurs.
With choosing a nursing home, “This decision-making cannot be done without physician involvement,” Nazir said, recommending hospital physicians work directly with nursing home medical directors, particularly on behalf of patients with complex medical needs. Families should inquire how often the nursing home physician will visit their loved one and if the nursing home has a nurse practitioner on staff. Ask if the medical director is certified by The Society for Post-Acute and Long-Term Care Medicine. Said Nazir, “I want to send my patients to a place where someone who is credible is seeing them.”