Skilled nursing facilities (SNFs) can be a valuable next step after hospital care, helping patients regain their strength and rehabilitate after an illness, injury, or surgery. However, they’re only a short-term care option, after which patients need to transfer somewhere else. The question is, where? In this post, we highlight the various options while examining how patients and their families can determine the best senior care option after rehabilitation.

Preparing for discharge from a skilled nursing facility

As you are preparing for discharge from a skilled nursing facility for a short-term rehabilitation stay, you’ll likely meet with the facility’s social worker or the individual handling your discharge.

The patient should receive notice that they’ll be discharged a few days prior to the discharge date. Though the title of the facility staff member might vary depending on the facility, typically the facility social worker or case manager will inform the patient that they will be discharged from the facility. 

Learning of the upcoming discharge date can be daunting to the patient. Even if the patient has met their rehabilitation goals and has improved significantly from their status upon entering the facility, knowing that they’ll leave can feel scary. It’s important to know that patients can appeal a discharge if they feel it is premature. You can learn more about discharge appeals on Medicare’s website.

In most cases, being discharged from a rehabilitation stay is a sign of progress. Nonetheless, the patient may still require assistance in some areas when it comes to personal care and hygiene tasks, continuing with therapies to support further progress, or acclimating to a new or evolved medical condition. Some aspects of life you may need to consider include:

• Safely completing daily personal care tasks, like bathing, getting dressed, feeding, moving around the home (ambulating), or getting in and out of bed (transferring).
• Doing household tasks, like laundry, preparing meals, or maintaining the cleanliness of the home.
• Driving and running errands like grocery shopping.
• Establishing and maintaining a medication schedule.
• Coordinating and getting to follow-up medical appointments and scheduling ongoing therapies as recommended by the skilled nursing facility medical staff.

If you’re in this position and wonder how you’ll take care of these items, there is help. Here are the options for getting the care you need after being discharged from a skilled nursing facility after a hospitalization.

Senior care options after rehabilitation

A person’s care needs will determine the best location for them after rehabilitation. These needs will typically be highest when the individual first leaves the facility and then decrease as they recover. They will eventually reach a new baseline, which could involve a lower level of function than their pre-hospital baseline. When considering the best location, consider how the senior’s health may change. For example, people with degenerative conditions like Alzheimer’s disease will experience a continued decline with increased care needs over time. Let’s take a look at senior care options after discharge from a skilled nursing facility.

Move to a senior care facility

Senior care facilities offer a structured environment designed to support seniors who can no longer safely live independently. There are various types, all with their own entry criteria and specific features.

Choosing independent living

Independent living can refer to being part of a retirement community or being in an independent living wing of a senior care facility. Whatever the context, residents are responsible for looking after themselves and don’t need physical or medical assistance but typically live maintenance-free lifestyles, with staff possibly taking care of tasks like housekeeping and laundry.

To move or return to independent living, a senior must leave rehabilitation in decent health. Sometimes, the senior may be able to hire professionals to provide short-term support, but this won’t always be an option, depending on the community’s rules.

Choosing assisted living

Assisted living facilities provide support with activities of daily living (ADLs), such as dressing, grooming, bathing, incontinence care, and meals. The facilities allow residents to remain as independent as possible while providing plenty of social opportunities.

Assisted living typically doesn’t provide medical care, so it’s poorly suited for anyone with significant medical needs. This type of facility is best for people who leave rehabilitation with personal care needs. For example, someone with limited mobility might be a good fit, but someone who needs regular wound care would not be.  

Choosing a nursing home

Nursing homes are like skilled nursing facilities, providing medical support and daily living assistance. However, while skilled nursing facilities focus on rehabilitation, nursing homes are long-term care facilities. These two care types are often in the same facility, with the term “nursing home” referring to long-term care and “skilled nursing facility” referring to short-term stays in the same building.

As a result, nursing homes are best for seniors with significant medical needs, such as wound care, pain management, monitoring vital signs, and medication management. These facilities are particularly well suited to seniors with complex health conditions and those with degenerative conditions likely to need more care over time.

Choosing memory care

Memory care may be offered in an independent facility or as part of another facility type, such as a wing in an assisted living facility. Either way, the care is specifically designed for those with memory-related conditions, including dementia.

Memory care is well suited to individuals with disruptive dementia behaviors (like aggression) or behaviors that put them at risk (like wandering). Some memory care facilities may also provide medical care, especially if they are part of a nursing home. Still, checking with the facility ensures they can meet your loved one’s medical needs.

Choosing a continuing care retirement community (CCRC)

Continuing care retirement communities (CCRCs) offer multiple levels of care on a single campus. Many include independent living, assisted living, skilled nursing care, and memory care, allowing residents to move from one level of care to the next by moving to a different part of the campus.

These communities provide residents with security, as their health needs will always be met. They also reduce stress, as moving within a community is much easier than living in an entirely new facility.

Because the care level varies, CCRCs are suitable for pretty much anyone, although it’s important to note that these facilities may have admission criteria, such as the individual not requiring any personal or medical care upon admission. Also, these communities can be costly and offer little financial support. Thus, they are best suited for seniors who can afford the high entry fees and who want extra security for their future care needs.

Return home with short-term home health care

Returning home is a standard option, especially for seniors who remain relatively healthy following their skilled nursing facility stay. If they continue to need some skilled, clinical services after discharge, the doctor from the SNF may certify that they need short-term home health care, which may be covered under Medicare. 

Home health care, which differs from home care, is medically focused and includes tasks like injections, medical tests, pain management, and physical therapy. This care is provided by medical professionals and is typically much less intense than that found within a SNF.

Some individuals may require only home care, which is nonclinical care similar to that found in an assisted living facility. Here, nonmedical caregivers help with tasks like bathing, dressing, grooming, meal prep, and toileting. Medicare typically does not cover home care alone but may cover short-term assistance with some of these tasks if deemed medically necessary and occurring alongside home health care.

Return home with no professional assistance

Finally, the senior could return home with no professional support. This is most viable if they have recovered enough to care for themselves independently. Family members may act as caregivers to help the senior recover during this period.

Potential caregivers should consider this carefully, as the support role can quickly start simple and gradually become more intense over time. If the seniors cannot support themselves after a few months, it may be time to consider alternative care arrangements.

How to get help with deciding on senior care options

Patients and families can consult with a discharge planner, social worker, or doctor in the skilled nursing facility about their senior care options. They can also seek guidance elsewhere, such as with the patient’s former primary care physician and other family members — sources that have known the patient longer than the skilled nursing facility staff. There are also external professionals, like senior placement advisors and senior living advisors. Such individuals can help families determine the best senior care option for their loved one.

Senior care facility rules and requirements vary based on company-specific policies and state-level regulations. The content above represents common guidelines but may differ from a particular facility’s policies or requirements. To learn the regulations that apply in your state, contact your local Oasis Senior Advisor.