Skilled Nursing Guide

Learn all about skilled nursing facilities including cost,
what to look for, and when it is the right choice.

What is skilled nursing?

Skilled nursing encompasses higher level care needs such as complex wound care, tracheotomies, significant mobility issues, IV drug therapies, and complicated chronic conditions.

Rehabilitation is physical, occupational, speech and respiratory therapies. It is short term, typically lasting from a week to 100 days. Rehabilitation in a skilled nursing home is a Medicare benefit.

Long-term care is also available in some nursing homes. This is for those who need more care and support and cannot safely live on their own. They need help with daily care and medication management or have very high care level needs, as mentioned above.

How much does skilled nursing cost?

For short-term rehab or skilled care, Medicare will pay the first 20 days of a qualified stay at 100%. Medicare pays days 21 thru 100 at 80%. If a patient has a supplemental policy, that will cover the remaining 20% copay. This is for a duration of 100 days, providing a patient is actively engaged in therapy.

For those needing care outside of qualifying for Medicare, skilled nursing in the U.S, averages about $290 a day, which can be from private pay funds or private insurance that is not Medicare.

Medicaid pays for long-term custodial care as the payor source for the financially indigent. Residents can also private- pay for this type of care, until funds deplete and then convert to Medicaid. People who are long-term are referred to as residents, not patients, because this is their home.

How to know if skilled nursing is the right choice?

  • In-patient rehabilitation that is paid for by Medicare is only available where skilled nursing is offered. A patient must have a three- night qualifying hospital stay and doctor's orders to be eligible for Medicare benefits.
  • There are two options for in-patient rehabilitation. Acute rehab will occur in a hospital therapy unit and is a higher level of intensity. It can be between 3 and 4 hours of different therapies daily. It may also be a stand- alone building. Acute therapy is for patients who are recovering from acute illness or debilitating injury or surgery. As an example, patients that have had a stroke may be candidates for acute therapy.
  • Sub-acute rehab will occur in a skilled nursing facility or skilled nursing wing of a larger campus and the therapy session duration is less intensive. It could be 1-1/2 to 2 hours of therapy daily. Sub-acute rehab is well suited for patients who do not have the energy, mobility or strength to handle the rigorous schedule of acute therapy. They may be recovering from a surgery or an illness.
  • Either acute or subacute therapies can happen in a hospital setting, a stand- alone building or part of a larger campus. Prior to discharge from the hospital, the physician and therapists will determine if acute or subacute rehab is most appropriate.
  • Out-patient therapies happen in an out-patient facility or at home with home health services.
  • If a person's needs exceed what can be done in assisted living, long-term care in skilled nursing would be the next step.

Questions to ask when touring a skilled nursing facility for short term rehabilitation

Do you adjust rehab session times to meet my loved one's best time of day?

There can be a few therapy sessions a day, as directed by Medicare. Depending on the time of day and energy of a patient, they may not have the best session if they are tired. They may have a significant amount of energy in the afternoon versus morning. Asking if they can adjust the therapy times to meet the patient's best times of the day can lead to better therapy sessions, therefore better recovery.

Will there be therapy 7 days a week?

This can be helpful if a patient could not complete a therapy session because of pain or exertion. Being able to make a session up over the weekend can maximize recovery efforts by using up all the allotted minutes per week of therapy.

If my loved one is discharged from the hospital on Friday, will they start therapy on Saturday?

It can be very frustrating for a patient to arrive at skilled nursing for rehab from the hospital and nothing would be scheduled until Monday morning.

How will pain be managed?

Pain or discomfort can be a hinderance to having a good therapy session. If this is an issue, will nursing take consistent measures ahead of scheduled therapy sessions such as pain relief medication given so it has time to take effect?

Besides rapid improvement, what would be a reason for an early discharge?

If there is no activity or improvement, they can discharge a patient from therapy. This often comes as a surprise to many, as they are unaware that this could be a possibility. As an example, this can happen if a patient has dementia, as some patients cannot receive direction and retain it from the therapists from session to session. The duration of the therapy sessions is more than they can cognitively manage. If a patient refuses their therapy sessions or is not progressing could also be cause for early discharge. This has little to do with the facility, as they must follow Medicare guidelines.

Other important questions

  • When will we discuss my loved ones progress?
  • Who will the care plan meeting be with?
  • How much notice will we get prior to discharge?

Questions to ask when touring a long-term nursing home

Ask to tour both the long-term care area and the short-term rehab area.

These are two different areas in the facility with different funding. It is wise that you are aware and do not have the same expectations for long-term custodial care as what they show in short-term rehabilitation.

Will my loved one have a private room or shared?

If a resident is private paying, there may be a private room accommodation, but if Medicaid is one's payor source, Medicaid has a stipulation that they will pay for shared accommodations only.

More questions to ask for long-term nursing home care

  • What if my loved one does not get along with their roommate?
  • How will I be notified if there is a change of condition in my loved one?
  • My loved one has limited funding. How long is the wait list for a Medicaid bed?
  • Will there be a Medicaid bed available they release when my loved one from therapy?

Selecting a skilled nursing rehab that could have a Medicaid bed available upon discharge can be a good option for those with limited funds and cannot return home or live independently. Medicare funds for rehabilitation are reimbursed at a much higher rate than Medicaid. Medicaid beds can be scarce. It may be a good incentive for the facility to help out in the Medicaid bed search.

If converting to Medicaid after short-term rehab, ask if the Discharge Planner will help find an open Medicaid bed in the area, if they do not have a bed available upon discharge from rehab.

Another suggestion when touring is to meet the Administrator and the Director of Nursing of the facility. This is the top level of leadership and you should know who they are and get a feel for how responsive they are. They should be happy to take a few minutes to say hello and introduce themselves.

Every skilled nursing facility has to undergo a very rigorous visit from the state to ensure that all protocols are being followed. This is an annual inspection. It is called the state survey. The results of the annual survey are available to be viewed either online or the facility will have a copy. You will be able to see how the facility scored and the what the deficiencies are. For any deficiencies, the state mandates a corrective plan of action within a certain time frame. It can give you good insight into how well the facility scored and help you be aware of some areas that may need improvement.

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