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  1. What are the levels of care provided in skilled nursing facilities?

  2. What types of interdisciplinary care services are provided at skilled nursing facilities?

  3. What are the roles and responsibilities of hospital and facility providers in ensuring adequate transitions to and from the hospital?

  4. What is the future of skilled care after hospital discharge?

With the assistance of hospital interdisciplinary professionals, hospitalists plays an integral role in ensuring timely and efficient discharge planning for a spectrum of patients, including those who require skilled nursing or nursing home care. Having knowledge of both the level of care provided as well as the challenges in care transitions to these settings is imperative.

Skilled nursing facility (SNF) or “subacute” care is provided mostly after an acute hospitalization, and consists of nursing or rehabilitative services that may not be practical on an outpatient basis, like intravenous injections and frequent physical therapy. These facilities are a common site for hospital discharge: 12% of all discharges in 2006 were to “long-term care and other facilities.” Knowing about the types of services provided at SNFs is important for hospital-based physicians, as the scope and intensity of the care their patients will get after they are discharged to these facilities will differ significantly from that which they will have received in the hospital up to that point.

Long-Term vs Subacute Care

There are two major categories of patients in nursing homes: those who reside in the facilities and receive long-term care, and those who are admitted for SNF care, most often following hospitalization. These two groups differ in terms of their clinical features, as well as in the financing sources for their nursing facility stays.

Long-term care is the more traditional service provided in a nursing facility. These “residents,” as they are called, when they stay in a nursing facility for the long term, receive custodial care and help with their Activities of Daily Living (ADLs), and have their medications administered to them by a nurse. Of note, elder caregivers' most common reasons for seeking placement are difficult-to-manage, dementia-related behaviors, as well as increased functional needs. Long-term care is not reimbursed by Medicare, so as a result, residents have to pay for their stays out-of-pocket, until the cost of their care exceeds their income (“spend down”) to qualify for Medicaid, which does cover long-term nursing facility stays.

Skilled nursing facility care may be provided in freestanding nursing facilities or hospital-based units, though the trend has been toward freestanding community-based facilities. Hospital-based facilities made up only 7% of all SNFs in 2008, compared to 12% in 2000. These units provide services for posthospital stays, mainly for the purpose of rehabilitation, wound care, or other postacute care. Skilled nursing facility care is reimbursed by Medicare and many other private insurance programs, at a higher rate than Medicaid, which may explain the growth in this sector as a percentage of ...

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