Medicare beneficiaries often need care in a Medicare- participating skilled nursing facility (SNF) after an inpatient hospitalization. For these patients, hospitals are responsible for identifying skilled nursing facilities within the geographic region that can meet the patient’s medical needs. Until such a placement is found, the beneficiary will not be responsible for her hospital stay. However, once a placement is found, if the patient no longer needs a hospital level of care, he or she will become financially responsible for his or her continuing hospital stay. Unfortunately, patients, families, and friends are often not happy with the hospital’s proposed skilled nursing facility choices. Here are some tips to help Medicare beneficiaries, their families and friends evaluate identified placements and to potentially identify better options.
The following may be helpful in assessing and choosing a nursing facility:
- Elder Care Locator (Information about local resources for persons in need of elder care): http://eldercare.gov/ (site visited May 15, 2015)
After typing in your zip code or the city and state where you reside, the Elder Care Locator provides contact information for local area agencies on aging, state agencies on aging, health insurance counseling programs, legal services, and the Long-Term Care Ombudsman. As more fully discussed in the glossary below, these agencies can help you identify and evaluate nursing facilities.
- Research the Facility on the Internet
While Nursing Home Compare can be helpful, it is important to visit the websites of particular facilities. It is also important to review newspaper articles and discussions about the quality of care and treatment of residents in particular facilities. Reviewing available written written commentary from current and former residents and their families can also be helpful.
- Nursing Home Compare (A website that allows one to compare nursing facilities in a given location) http://www.medicare.gov/nursinghomecompare/search.html (site visited May 15, 2015)
Nursing Home Compare, developed by the Centers for Medicare & Medicaid Services (CMS), uses a 5-star rating system to classify the quality of care in a given Medicare-participating SNF. Although potentially helpful, ratings through Nursing Home Compare should not be the major factor in choosing a facility, as many of the quality ratings criteria are self-reported by facilities (See https://www.medicareadvocacy.org/the-myth-of-improved-quality-in-nursing-home-care-setting-the-record-straight-again/ site visited May 15, 2015). Information available through Nursing Home Compare includes:
- Five Star Quality Ratings Generally (A brief explanation of the measures on which the 5 Star Rating system is based): http://www.medicare.gov/NursingHomeCompare/About/Ratings.html (site visited May 15, 2015).
- Inspection and Complaint Information (How to read inspection and complaint information): http://www.medicare.gov/NursingHomeCompare/About/Inspections-and-Complaints-Info.html (site visited May 15, 2015).
- Staffing Information (Staff found in nursing homes and how staffing measures are reported): http://www.medicare.gov/NursingHomeCompare/About/Staffing-Info.html (site visited May 15, 2015).
- Quality Measures (How quality measures are reported): http://www.medicare.gov/NursingHomeCompare/About/Quality-Measures-Info.html (site visited May 15, 2015).
- Penalties (Common penalties assessed against skilled nursing facilities): http://www.medicare.gov/NursingHomeCompare/About/Penalties-Info.html (site visited May 15, 2015).
Once you have developed a list of potential facilities, a site visit can be helpful in evaluating the facility's level of care capacities, quality, and feel.
Things to Consider Before Your Visit:
- Addressing Your Individual Needs: Call the facility and ask for a specific accommodation such as meeting special dietary needs. See how they respond. Are they helpful or are they dismissive? Do they seem rushed when speaking to you?
- Special Services: When a facility advertises that it offers certain services such as physical therapy, be aware that the Nursing Home Reform Law requires all nursing facilities to provide skilled nursing and therapy services designed to accommodate a patient's specific health needs, and provide necessary durable medical equipment.
Planning Your Visit:
- When to Visit: Visit during meal times, evening hours, on weekends and at times when staff shifts are changing. Observing these important time periods can provide insight into the culture and practices of a particular facility. Nursing homes often look best on weekdays during the day, when more fully staffed.
- Location: Be aware of the location of the nursing home. The closer the patient is to friends and family who can visit regularly, the better. Choosing a location in or close to the patient's neighborhood (or within a reasonable driving distance) may be preferred as it can give residents a sense of comfort and connection.
Other Observations of Potential Nursing Facilities:
- Smell Test: Be aware of the smell of the facility. The smell of urine indicates a facility that does not adequately take care of incontinent patients. Conversely, a strong smell of disinfectant could indicate that the facility is hiding other odors.
- Look Test: Do not be too easily impressed by the lobby of a facility. While a clean and impressive first floor could indicate good care throughout the facility, it also could just be a façade. Tour several areas of the facility, including the dining room (are residents engaged in conversation with each other? Helped to eat if they need assistance? Are residents eating their meals? Do meals look appetizing?). If possible, and with the permission of the resident, visit a resident's room (is the room personalized? Is there privacy?). Observe the interactions of staff and residents (does the staff greet residents by name or do they appear rushed?)
- Restraint Use: The Nursing Home Reform Law bans the use of restraints (physical or chemical) that are not required to treat the patient's actual condition. Ask about restraint use. Look around to see if physical restraints are being used. Identifying the use of chemical restraints is more difficult. For that, it may be best to look at federal survey reports about a particular facility.
- Lost Items: Ask how the nursing home addresses the prevention of the loss or theft of a resident's belongings.
- Talk to Residents/Visitors: When staff members are not present and with the permission of a resident or visitor, try to get a sense of his or her satisfaction with the facility. Ask if there is a family council and, if so, for the name of a contact person on the council.
- After You Have Gathered Information
When you have completed gathering information and have identified your preferred facilities, communicate your preferences to the hospital's discharge planning staff and to your physician(s).
- If You Do Not Feel Ready to Leave the Hospital at Discharge
If you do not feel ready to leave the hospital at the time you have been discharged, you can appeal the hospital's discharge decision. Detailed instructions on how to do this can be found at: https://www.medicareadvocacy.org/medicare-info/discharge-planning/#appeal (site visited May 15, 2015). See also http://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html (site visited June 1, 2015).
- Other Helpful Resources
- Long Term Care Planning (Information and resources for long-term care planning): http://longtermcare.gov/ (site visited May 15, 2015).
- National Long-Term Care Ombudsman Resource (Long-term Care Ombudsman can further assist you in finding and placing yourself in a nursing facility): http://www.ltcombudsman.org/ (site visited May 15, 2015).
- Alternatives to a Nursing Facility
- Inpatient Rehab Facility (CMS's coverage criteria are listed under 42 C.F.R. §412.622(a)(3)): http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec412-622.pdf (site visited May 15, 2015).
Since most people prefer living in their own homes, explore the possibility of returning home for post-acute care and services.
- Home Health Services (General overview of Medicare-covered home health services and who is eligible for them): http://www.medicare.gov/coverage/home-health-services.html (site visited May 15, 2015).
- Home Health Compare (CMS's evaluation of home health services in your area): http://www.medicare.gov/homehealthcompare/search.html (site visited May 15, 2015)
- National Association of Professional Geriatric Care (A non-profit organization that assists older adults with long-term care arrangements): http://www.caremanager.org/ (May 15, 2015)
9. Further Understanding Your Healthcare Plan
For persons using health plans under Medicare's coordinated care options (Medicare Advantage (MA), including HMOs, PPOs), it is important to understand what your health plan covers and its network limitations. It is also important to have a current list of the physicians and specialists in your plan's provider network. This information should include the services covered by your health plan, the costs you must cover (copayments, deductibles) and what you must pay when you use plan providers or when you use service providers who are outside your plan's network. Keep in mind that the cost of using out-of-network providers may be higher than it would be if you use in-network providers. And, depending on the plan, it may not cover any of the cost of using out-of-network providers without first obtaining the plan's approval. A set of tips that can be helpful as you explore your Medicare Advantage plan options is available at: http://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/questions-when-looking-for-a-plan.html (site visited May 15, 2015) and http://www.huffingtonpost.com/bob-rosenblatt/medicare-advantage-plans_b_4275652.html (site visited May 15, 2015).
Useful Terms and Organizations
- Area Agency on Aging (AAA): AAAs are described as “A public or private non-profit agency designated by the state to address the needs and concerns of all older persons at the regional and local levels. By providing a range of options that allow older adults to choose the home and community based services and living arrangements that suit them best, AAAs make it possible for older adults to remain in their homes and communities as long as possible.” For more information go to: http://eldercare.gov/Eldercare.NET/Public/About/Aging_Network/AAA.aspx (site visited May 15, 2015).
- Acute Care Hospital: A hospital where the average length of stay is 25 days or less and patients generally receive intensive but short-term care.
- Health Insurance Counseling and Assistance: These programs are also known as Health Insurance Counseling Programs (HICAPs). In general, they utilize “paid professionals and trained volunteers who offer unbiased, one on one counseling to help consumers understand their Medicare health insurance benefits and resolve billing problems. They also address issues related to supplemental insurance and long term care insurance options." For more information, see: http://www.seniorsresourceguide.com/directories/National/SHIP/ (site visited June 1, 2015).
- Inpatient Rehabilitation Facility: CMS states that inpatient rehabilitation facility (IRF) benefits are "designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care."
- Legal Assistance: Legal assistance programs exist in most states and often have funding through the Older Americans Act (OAA), the Legal Services Corporation (LSC). Others receive a variety of local, state, and federal funding. Programs for the elderly and disabled focus on persons who are 60 years of age and older and younger disabled persons. They generally provide assistance in the area of tenant’s rights, health and aging services, federal benefits, and consumer protection matters. A useful reference for finding legal assistance programs can be found at: http://www.lsc.gov/find-legal-aid (site visited June 1, 2015).
- Long-Term Care Ombudsman Program: The Long-Term Care Ombudsmen program is comprised of advocates for residents of nursing homes, board and care homes, assisted living facilities and similar adult care facilities. The long-term care ombudsman helps individual residents to resolve care and services issues in facilities with respect to resident’s rights and access to necessary services. For more information, see: http://ltcombudsman.org/(site visited June 1, 2015).
State Agency on Aging: State Agencies on Aging, units of state and territorial governments administer, manage, and design services and programs for persons 60 and older and younger disabled persons. See http://aoa.gov/AoA_programs/OAA/How_To_Find/Agencies/find_agencies.aspx (site visited June 1, 2015).Conclusion
Although choosing a nursing facility is often a stressful life event, being aware of one's rights is an important aspect of the process of finding a nursing facility that meets the needs of the Medicare beneficiary.
 For information on assessing nursing home quality, see http://assets.aarp.org/www.aarp.org_/promotions/text/life/NursingHomeChecklist.pdf (site visited May 15, 2015); see also http://theconsumervoice.org/issues/family/fact-sheets#Selecting%20a%20Nursing%20Home (site visited May 15, 2015).
 Definitions can be found at http://eldercare.gov/ (Site visited at May 15, 2015).
 Available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c01.pdf (Site visited May 15, 2015).