By Melinda Young


Too often, patient information is lost or inadequate during transitions from hospital to skilled nursing facilities (SNF). This causes challenges that case managers can help overcome.

• Write a thorough discharge summary that is forwarded to the SNF.

• Tell SNF contacts about all of patients’ safety issues and concerns.

• Time the transition to when it is most appropriate for the patient.

When hospital patients transition to a skilled nursing facility (SNF), there are hurdles that must be overcome. For example, patient information can be lost, misconstrued, or inadequate.

“Sometimes, information can get lost in translation from one facility to another,” says Claire Wueste, LICSW, CCM, CBIS, case manager at Spaulding Rehabilitation Hospital in Boston.

Patients’ expectations also can be different from what will happen next at the SNF. For instance, patients with Medicare coverage might expect that they can stay in a nursing facility over a longer period when the coverage is only for a short time, during which they must show progress. Case managers also can help patients and families find the right SNF for their needs. (See story on finding the right SNF in this issue.)

“If someone has Medicare, I explain what’s covered and what skilled nursing care is,” Wueste says. “If someone needs a longer-term stay or has plateaued with their progress, the options are Medicaid or private pay. We have a financial counselor who can start that process here if they need that.”

Wueste provides this information on how to improve the hospital-to-SNF transition:

• Communicate well and fully. “We do a good job of putting together a thorough discharge summary,” Wueste says. “All the clinicians who work with patients perform a discharge summary.”

These include physicians and therapists. They forward the document to the facility, giving SNF clinicians time to review it before meeting with patients, she adds.

Using an electronic medical record (EMR), the hospital includes specific communication and patient summaries in the notes and history that can be referred to community providers, including SNFs. “We have a good system that is used by a lot of hospitals to send information to multiple facilities at once and to have back-and-forth communication to make sure they accommodate the patient’s needs,” Wueste says.

Electronic communication can expedite the transition. If the SNF needs a copy of the healthcare proxy, the case manager can quickly send one. The case manager can quickly respond to any questions.

“If a patient needs quite a bit of assistance, the SNF might be concerned they’d be a long-term patient,” Wueste says. “I would communicate what information I have from the family about their intentions.”

For example, the patient might need to take a leave of absence from work, ask multiple family members to help, or can build a ramp to make the home discharge possible, she explains.

“We also do a warm handoff with nursing,” she says. “Case managers will obtain a phone number for the nurse at the incoming facility and give a nurse-to-nurse phone call.”

Case managers can give SNF staff information about the patient’s pain issues and any specialized nursing concerns. “We don’t do this with every case, but we’ve done it with the more complicated patients,” Wueste says.

• Address patients’ safety needs. “Skilled nursing facilities are able to do restraints, so we make sure they have a sense of what someone’s safety needs are,” Wueste says. “We have people who still might be a high risk for falling, and we want to make sure someone at the incoming facility knows this risk.”

This way, the SNF can place the patient near a high-traffic area, which ensures there are people walking by who can help the patient soon after a fall, she adds. “We make sure they have a good sense of the patient’s safety needs,” Wueste says.

• Provide updated therapy information. “We never want patients to lose ground when they go to another facility,” Wueste says. “Sometimes, there might be a change in terms of the frequency of therapy — slightly shorter sessions than what we do at our hospital. It could be they provide therapy three times a week instead of five times a week, so we try to be clear about what level the patient is functioning at.”

Patients’ families sometimes ask about the frequency of therapy at the SNF. They are considering various SNFs and want to know what will change in the person’s care.

“We emphasize that the patient is there for continued rehab and will continue to benefit from continued rehabilitation,” Wueste says. “The goal is to make it very clear to the facility and also to the family that we can’t tell them how much therapy the patient will receive at the next facility,” she adds. “But we do prepare patients and families by telling them it will be a little different than what they get here.”

• Time transitions appropriately. “We try to time the transition to the skilled nursing facility to when it’s most appropriate for the patient,” Wueste says.

This timing depends on when the patient is at a level where he or she can continue to progress at a SNF and when the patient no longer needs an acute rehab level of care, she explains. “But the patient still has goals to work on,” she adds.

• Discuss insurance issues. “Sometimes, insurers don’t want to approve that level of care, even if the patient has coverage for it,” Wueste says. “We try to set the stage for families, telling them there will be a similar process where the facility has to get approval on a week-to-week basis. The patient will make continued gains and stay at a skilled level of care.”

This is challenging. It requires a case management-style of patient advocacy — even to get the patient approved to go to a SNF, she adds. It might even require the doctor calling the payer’s medical director to advocate for a SNF transition: “They might say, ‘This is a patient who could go home,’ and we say, ‘We feel strongly they need skilled nursing facility care.’”

• Help patients and families adjust expectations. “Usually, I can anticipate what the questions are going to be before I make the referrals, so I try to have that information in advance and have a discussion with the family,” Wueste says.

She might ask patients and families these questions:

- At what level of functioning does your loved one need to be to go home?

- Will you need home modifications? Could these start early, before the patient is transitioned to the next level of care?

- What additional information do you need?

“We develop a relationship with the family and see what they know about the longer-term plan,” Wueste says. “We have a home accessibility questionnaire that therapists will give to families to get more information about their home.”

The questionnaire asks about stairs, width of doorways, and bathroom measurements, such as the height of the toilet and sink. “It also has ADA recommendations in it so the family knows what the standard would be if they do have to make modifications,” Wueste says. “We have the family fill it out while they’re here, and give recommendations.”

The goal in working with families is to be supportive, she notes. “As case managers, we develop relationships with the family,” she adds. “We also coordinate families to come in and participate in therapy sessions, so they can actually see what a person is able to do, instead of just hearing it described over the phone.”