Hospital Discharge Guide
Part 3: Discharging to a Recovery Facility vs. Home
The goal of this guide is to prepare you for the discharge process. We will walk you through a hospital discharge—important considerations, the key players involved, and steps to take after discharge. This guide is useful for patients of all ages. However, if you need help during the discharge process, contact our expert team at 650 462-1001 to help you coordinate post-hospital care for your loved one.
Here is an overview of the hospital discharge process. If you would like to jump to a particular section, click the corresponding heading.
Recovery Facilities vs. Home
Although many people prefer to go home, it is not always the best option. A discharge planner will evaluate the safety and effectiveness of each recovery option and present their recommendations to the patient. From there, the patient has the authority to choose or open up a discussion on their preferred solution. Remember, the discharge planners have your loved one’s health as their primary focus, and their recommendations should be taken seriously.
Acute Rehab or Skilled Nursing Facility (SNF)
Inpatient services may be a necessary option. Rehabilitation and skilled nursing facilities (SNF) are similar. It is not uncommon for SNFs and rehab facilities to exist as different floors within the same building. The main difference between a skilled nursing facility and a rehab facility is that people usually spend a longer time in SNFs.
An acute rehabilitation (rehab) facility is a place where specialized medical care and/or rehab services are offered to injured, sick, or disabled patients. Services may be provided by nurses and other health care professionals, such as skilled therapists, speech pathologists, and other specialized medical staff.
A rehab facility can provide care for someone following a stroke, surgery, illness, or infection. These conditions may require IV therapies, antibiotic administration, wound care, or other forms of medical care. A stay at these facilities can be covered by Medicare for up to 100 days. Rehab facilities are regulated and certified by the federal government, as well as state and local laws.
Rehab facilities are not permanent residences. Hospitals typically refer patients for short- or long-term care, depending on their needs. After a rehab facility stay, patients are discharged to the home, a nursing home, or other permanent residence.
A skilled nursing facility (SNF) provides skilled nursing care and/or rehabilitation services. Generally, services that are available in a SNF include nursing care by registered nurses, bed and board, physical therapy, occupational therapy, speech therapy, medical social services, medications, medical supplies and equipment, and other services necessary to the health of the patient. Like rehab facilities, staff may include licensed nurses, skilled therapists, and other specialized medical staff.
Medicare offers 20 days of full coverage in a SNF, if Medicare coverage requirements are met. After that, Medicare pays for covered services—except for a daily co-insurance pay—for days 21 through 100.
Your loved one may be eligible for Medicare coverage for their skilled nursing facility care if:
- They have Part A and days left in their benefit period.
- They have a 3-day qualifying hospital stay where they have been admitted as an inpatient, and they are admitted to a SNF within 30 days of a hospital discharge for services related to their hospital stay.
- Their doctor certifies that they need daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff.
- They get care in a skilled nursing facility that is Medicare certified.
Let’s discuss the advantages and disadvantages of staying in a rehab or skilled nursing facility.
Inpatient care has a multitude of benefits for the recovery process. These facilities should have adequate professional and material resources to address the patient’s medical needs. Your loved one will have access to and benefit from specialist treatment to ensure a smooth, steady recovery.
Stays in these types of facilities tend to be a few weeks—not months. After a few weeks, the patient will be transferred from the facility to their home, a nursing home, or another form of permanent residence. If rehab or skilled nursing services continue to be required, then the patient may use outpatient services, such as an adult day health center, or bring in private duty nurses or caregivers.
Medicare typically covers a stay in these facilities. In SNFs, Medicare can cover weeks of care if the patient demonstrates progress in therapy or if their condition is unstable enough to require around the clock skilled nursing care.
One of the biggest advantages to staying in a rehab or skilled nursing facility is the assurance and peace of mind that comes with supervised care from skilled professionals. Licensed nurses, CNAs, and other medical staff are on location 24/7 to ensure a smooth recovery for your loved one.
Depending on your perspective, a few weeks in one of these facilities can feel like a long time. If home is a safe option, a rehab or skilled nursing facility may not be your preferred choice.
Although Medicare typically covers these stays, coverage is not guaranteed. Patients may sometimes be obligated to pay for care which should be covered by Medicare. Once acquired, coverage may be subject to regular evaluations of the patient’s condition. Determine what coverage you may be getting before being discharged from the hospital, and call your insurance provider if you have any questions about coverage requirements.
An extended stay in an inpatient facility can increase the risk of infection or illness due to the close proximity of patients recovering from illness. Infection or illness interrupts recovery and increases the risk for hospital readmission. Unfortunately, healthcare-associated infections are a major—yet preventable—threat to patient safety.
A lengthy stay can lead to depression and inhibit recovery. Care in a rehab or skilled nursing facility is structured, and there are often schedules for everything, including set shower times. Patients may feel institutionalized, or bedbound.
Care staff may be spread thin and your loved one may not get the one-on-one attention they feel they deserve. A simple solution is to hire a private nurse to accompany your loved one at the inpatient facility. Supplemental care offers personalized attention and companionship, which are important parts of the recovery process.
Rehab facilities offer outpatient services for patients who have the ability to travel to and from appointments. Outpatient care facilities usually offer physical, occupational, and speech therapies. These facilities are only an option if your loved one’s care needs are not acute and do not require inpatient services.
If your family member’s needs are not acute and do not require inpatient services, outpatient care is a good solution. Your loved one can transition back to their permanent residence while getting the care and therapy they need.
During recovery, some patients may require therapy or specialized medical appointments multiple times per week. It may be tiring for your loved one to complete the journey each time. In addition, organizing transportation to and from these appointments can be demanding.
Communicate any concerns you have about outpatient services with your loved one and the discharge planner. Keep your loved one’s preferences in mind, but remember that their health is everyone’s number one priority.
Heal at Home
It may be possible for a patient to recover safely in the comfort of home with adequate post-hospital care in place. However, it must be supported by the discharge planning team.
There are a variety of advantages to recovering at home. Besides enjoying the comfort of familiar surroundings, healing at home greatly reduces the risk of infection or illness that is all too common in inpatient facilities.
Patients who recover at home can still receive expert care. Care professionals, such as private nurses and caregivers, can provide much more personalized attention in the home. Visits can range from a few hours to around-the-clock care. With 24 hour care, patients and families can rest assured knowing that a care professional is available at all times.
Skilled therapists can create rehab programs that are customized to the patient’s everyday environment. Recovery goals become more realistic, and more meaningful. A physical therapist can guide a patient recovering from hip surgery around their own home. It can feel far more motivating to walk around your home compared to walking laps around an unfamiliar facility. In addition, patients may experience a smoother transition back to their everyday routines.
A hospital stay can negatively impact a person’s mental health. Adults may feel fearful or that they lack control over what is happening to them. A well-rounded recovery includes reducing stress and promoting independence, health, and positivity. Fortunately, the psychological benefits of transitioning home go beyond physical therapy training.
Home health care and private duty nursing offer the greatest security and happiness for the client and the most peace of mind to their family.
Sometimes, transitioning home can be challenging. It may involve coordinating multiple agencies and care professionals. If this seems overwhelming, a case manager can help.
Case managers can:
- Coordinate with family, caregivers, and other medical providers
- Schedule and accompany patient to healthcare appointments • Order medical supplies, if necessary
- Communicate with all members of a patient’s care team, including the family, doctor and other healthcare professionals
It can be beneficial to have a case manager who is a licensed nurse. In addition to the above responsibilities, an RN case manager can assist with medication reconciliation and management, as well as prescription refills.
Home health care may be covered in part by Medicare, though there are many rules and regulations. Consult your loved one’s insurance provider to see what coverage works best for them. Typically, home care and private duty nursing care is an out-of-pocket expense.
Other forms of permanent residence may not have skilled aides on staff, so they cannot assist with skilled needs. You should know whether or not a residence has skilled aides before your loved one transitions to that facility. If the facility does not have skilled aides, a private duty nurse can provide personalized medical care for your loved one.
Private duty nurses are available for full-time care. They can support a range of skilled needs, including wound care, IV therapies, feeding pumps, and palliative care.
Skilled care can be especially beneficial for patients with more complex needs associated with an acute hospital stay or chronic conditions. Private duty nursing and other home care services can positively effect a patient’s recovery and overall quality of life following a hospitalization.
To learn more about how a private duty nurse can ease the transition into post-hospital care, call (650) 462-1001 to speak with a NurseRegistry Care Advisor.
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