What to know about transitioning from the hospital into a rehab facility

You or a loved one has entered the hospital for a planned surgery, such as hip replacement, or an unplanned injury or illness. The hospital is ready to discharge you. But you – and your doctor – feel you’re not quite ready to go back home. Where should you go? How much will it cost? Can you receive financial assistance?

Many adults and seniors find themselves in a challenging situation after a hospital stay, caught in the transitional phase between hospital and going back to their prior living situation in the community, whether it be home, an adult family home, or an assisted living facility.  This phase is often referred to as “skilled nursing care,” “rehab stay,” “skilled stay,” or “covered stay,” and involves stay for a time in a specialized unit in a skilled nursing facility.

At Providence Mount St. Vincent (The Mount), we use the term Transitional Care Unit (TCU) to describe our specialized place within the Skilled Nursing Facility (SNF) where we provide this service. While other SNFs may have different names for their TCU’s, at The Mount, all 206 beds in our skilled nursing facility are dual-certified (Medicare and Medicaid) capable of delivering skilled care throughout the building. However, we’ve designated our 5^th floor specifically as our TCU to ensure focused care for those recovering and preparing to return home. It is crucial to understand the significance of seamless transitions from hospitals to skilled nursing facilities within our complex healthcare system. This understanding fosters continuous care and enhances healthcare efficiency, especially as hospitals increasingly prioritize timely patient discharges. By embracing this knowledge, we can better support patients on their path to recovery.

This article will discuss the role of a TCU, what to know before you or a loved one goes to one, what to expect once there, and how to be prepared to return home.

The Discharge-Admissions Process – From Hospital to the TCU

The hospital care team typically determines whether a patient should be discharged to a SNF for rehabilitation or return home. Hospital will work with SNFs on bed availability and meeting clinical needs. It is important to understand that patients and families have the right to choose their preferred SNF.

There are many transitional care units in the Greater Seattle area, but a few of them are:

–             Providence Mount St. Vincent, in West Seattle

–             Seattle Medical Post Acute Care, in Seattle

–             Transition Care Program at UW Medical Center, in Seattle

–             Everett Transitional Care Services, in Everett

–             Avamere Transitional Care, in Tacoma

A good source of information on SNFs  is https://www.medicare.gov/care-compare/?redirect=true&providerType=NursingHome, which allows individuals to research SNFs and other care facilities by zip code. Ultimately the patient has the final say on where to go. Hospitals will coordinate discharge to the accepting SNF.

Health Insurance Coverage and Financial Support Through Medicare and Medicaid

Dealing with insurance is hardly any patient’s favorite part of any hospital visit. To avoid unexpected expenses and improve the transition process, it can be very beneficial for the patient or family member to call the insurance provider to clarify coverage.

Medicare is set up to pay for skilled nursing and rehab services after a hospital stay, as long as patients meet certain criteria, including having been hospitalized for at least three midnights.

Patients with financial means to buy private insurance and Medicaid patients seeking skilled nursing or long-term care placement will not require a three-night hospital stay. But those who are on a Managed Medicaid plan, such as Apple Care in Washington state, must receive pre-authorization from their plan to qualify for rehabilitation care in a SNF.

Given the complexity of insurance coverage and variations in coverage, patients must understand specific plan policies which can affect the coverage of equipment, medications and the duration of a (TCU) stay. Social workers and case navigators are instrumental in helping navigate these complexities, ensuring informed choices regarding facility transfers.

Depending on the specific plan, equipment and medications may be covered as well. The social worker and your care team are great resources to help you navigate how to successfully clarify Medicare and Medicaid eligibility for your specific case.

How long will the patient stay in the TCU?

It depends on the patient’s progress.

The length of stay in a TCU depends on a patient’s progress. Once a patient reaches a point where daily treatment is unnecessary, discharge to home or a different level of care like a long-term care facility or adult family home might be necessary. While Medicaid or long-term care insurance may cover these expenses with some patient participation costs, Medicare does not pay for long-term care, leaving patients responsible for out-of-pocket costs.

Having a successful return home

Before you return home, most facilities will schedule a care conference with your care team. This is a great opportunity to ask your care team how to optimize your chances of a successful recovery at home. Your provider and support team are the best people to guide you through that, based on your specific needs.

At Providence Mount St. Vincent, this care conference usually includes discussing any equipment or set up that may be needed, as well as discussing possible hands-on instructions to a family member who will be supporting the patient at home. Transitioning home after a TCU stay can be scary, and the Providence Mount St. Vincent team wants the patient and their family to feel comfortable and supported.

Maureen, the wife of a recent patient, posted on the Caring Bridge website that “We were impressed with the Mount’s ‘whole person’ approach, coordination of John’s current and future therapeutic needs, and personal care for John.”

Home health services can also be available for those who need/prefer additional support at home. Payment for that will also vary depending on your insurance, but it is an option worth exploring.

One thing important to remember is that it is not uncommon for patients to return to TCU care after going home should a healthcare condition worsen or a new issue arise. Each patient’s recovery is unique and your care team will be able to guide you each step of the way.

Understanding the transition from hospital to a SNF rehab stay can significantly ease stress and anxiety associated with recovery. By being proactive and informed, patients can ensure smoother transition and more effective collaborative recovery plans.

Maricor Gonzales-Lim, PT, DPT, LNHA, is executive director at Providence Mount St. Vincent.]