The Reality of Skilled Nursing Home Stays

The online journal Medscape published a Reuter’s article on Skilled Nursing Facilities and post hospital stays.  They discussed the often-lengthy time span between hospital discharge and the patient being seen by a physician or “an advanced care practitioner”.

Older, more infirm and cognitively impaired patients tend to be seen later than other patients. Apparently the later you are seen, the more likely it is that you will be sent back to the acute care hospital and be readmitted.  The study was conducted by Kira Ryskina of the Perlman School of Medicine at the University of Pennsylvania in Philadelphia. The researchers looked at Medicare claims from nearly 2.4 million patients discharged from acute care hospitals. Her data indicated that when patients were seen by doctors at the facility soon after discharge they tended to recover more often not requiring acute readmission to the hospital for the same problem.

The author went on to say that most families confronted with a family member requiring post hospital rehabilitation at a skilled nursing home do not know what to expect from a skilled nursing facility (SNF).  The truth is, most doctors who practice in the inpatient setting or in surgical and medical specialties have no idea what to expect. They have never gone into one, unless it is for their own recovering family member, and they have never cared for a patient on a daily basis in one.

My first month as a private physician in 1979, my employer took me to the local facilities to meet the administrators, charge nurses and social workers at the facilities. The medical director was a young internist who had no private outpatient office or practices just a nursing home practice at five institutions he called on.  I was told that the law required me to see new patients within 24 hours of arrival, examine them and write a note and review all orders and either approve or change them.  I was surprised that facilities were staffed with only one registered nurse per 40 patients. The RN was required to pass the medications each shift, with most patients being on multiple medications so that most RNs had little time per shift to do much else but pass the medications.

When a patient had a complication or problem the nursing staff called the family member and the doctor. The volume of calls was so immense that the young facility medical director could not find any physicians who would agree to cross-cover with him on the weekends so he could get some time off.  In most cases, even if I decided the phone call related medical problem could be dealt with at the facility, the family decided otherwise and wanted their loved one transported to the ER. Those of us who cared for patients at these SNF’s joked that the protocol for caring for a problem was to call 911 and copy the chart for transfer.

It used to disturb me that EMS services were being diverted to these facilities for non-critical issues taking them away from true emergencies, and delaying response times, but they seemed to like it.  The more trips they were called on, the more evidence they could present for a larger share of the city or county budget.

At some SNFs there was always an EMS bus or ambulance sitting in the parking lot outside.  The patients were insured by Medicare guaranteeing bill payment so the receiving Emergency Department and staff were happy as well.

We were required to see the patient monthly and write a note. I saw sicker and less stable patients more often than monthly.  Progress in rehabilitation was discussed at mid-day care planning conferences that the physicians were rarely made aware of.  My goal for discharge was when the patient could safely transfer from the bed to a walker or wheel chair, get to the bathroom and on and off the toilet safely and; get in and out of a car. If the family could convert their home into a “skilled nursing facility” the patient could go home as well.  Often the patient was sent home by the facility “magically cured” when their insurance benefits ran out.

Most of the work at the facilities is performed by lower paid aides. In my area of practice most of the aides are men and women of color from the Caribbean who have little in common with the mostly Caucasian elderly population they care for. The work is hard and the pay low with the employee turnover rate extraordinarily high annually at most institutions. The patients are elderly, chronically ill, often with impaired cognition, hearing, and vision. Their family’s vision of what should be done is vastly different from what can be accomplished.  I believe most of the staff are caring and well-meaning just under staffed and under trained.  Administrations concerns about liability from medical malpractice, elder abuse and other issues is well founded based on the plethora of ads on prime time TV, newspapers and the sides of travelling public buses touting law firms seeking elder care cases.

It is now harder and harder to actually see patients at these facilities even if you wish to.  While community- based physicians with local hospital privileges were once welcomed and encouraged to attend to their patients at the facility, now the facilities require doctors to go through a lengthy credentialing process – as if you were applying for hospital staff privileges.   When you actually show up and care for your patients you rarely see a physician colleague. Most of the care is assessed and provided by nurse practitioners and physician assistants working for physicians who rarely, if ever, venture into the facilities. They may supervise the care plan on paper but rarely lay eyes or hands on the patient.

These facilities serve a vital role in the post-acute hospital care of patients. According to this study and article, Medicare spent $60 billion dollars in 2015 on this care. When a hospitalized patient has a frail spouse or no spouse at home, with no local nuclear family able to provide home care, the SNF is the only real option.

I suggest families visit the potential choices first. Speak to patients and their families about the care and services.  Review online state inspection and violations records. Ask about the transition from the hospital to the SNF. Who will be responsible for caring for them at the facility?  Meet them and talk to them. Make sure you are on the same page. If you can find a facility that has an onsite physician team with a geriatrician as the chief medical provider.  It may be the best option.

For these transitions to work and save money by stopping the revolving door form hospital to SNF to emergency room for every medical question, the SNF’s need some form of sovereign immunity from frivolous lawsuits if their services and care meet the legally required standards. The recent post- hurricane heat-related tragedy at a Hollywood, Florida nursing home underscores the need for vigilant inspection and regulation of this industry. The good homes need to be identified and need to be given the support and latitude required to care for this ever increasing portion of our American society.

Where Do You Go To Die?

Question Mark v3A long-time patient in his mid-nineties, who lived an independent and full life style, became acutely ill six weeks ago. He lost his equilibrium and was unable to get up from a chair without having his blood pressure plummet and him faint.  When we could keep his blood pressure up, and he tried to walk, he ambulated like an intoxicated individual, swaying from side to side slapping his feet down like Goofy in Disney World.  CT scans of the brain, neck and spine, MRI scans of the brain, neurological testing, cardiac testing and multiple consultants in cardiology, neurology, and endocrinology could not find the cause of his problems. He did develop an aggressive and fastidious urine infection which improved with antibiotics.  It was hoped that with time, good nutrition and help from a team of occupational and physical therapists at a skilled nursing facility, we could return this sweet gentleman to his previous state of life. It did not work out that way.  Instead of improving he declined. He refused to eat or drink. He refused to consider intravenous nutrition or a feeding tube. He was judged by psychiatry to be sane and competent to make those decisions.   Trials of mood and appetite stimulants did not work. The decline occurred over a five day period at the SNF during which I called on him at least daily.

The patient and I had discussions about end of life issues yearly which we documented on his chart. The last discussion in January 2013 revealed that he did not want to be kept alive by machines but was not ready to sign a Do Not Resuscitate (DNR) order. He was against artificial feeding measures such as NG tubes and PEG’s.  As he declined clinically, I reintroduced that discussion to his wife and children.  I suggested we execute a DNR form and begin comfort measures. I asked them to consider a consult with Hospice but assured them we could provide comfort measures without them as well. They declined all help saying they were beginning to consider it but were not quite ready yet to make a decision. The SNF charge nurse was present at one of these discussions and to my surprise called me aside and said, “That man cannot die here. People cannot die here unless they execute a DNR or are in a hospice bed.”   I could not believe what I was hearing. We were in an old age home in a geriatric community with multiple custodial care patients plus the post-hospital rehab type patients.  The charge nurse then brought in the administrator who emphasized the same message. “He cannot die here.”

If the patient’s demise was imminent, the SNF wanted him transferred to the acute care hospital or else they threatened to call 911.    Where then are deteriorating patients supposed to die?  Hospice has become a bureaucracy unto itself and, while their efforts and works are admirable, the cost to Medicare is extraordinary.  Why can’t a deteriorating patient who is not uncomfortable or in distress expire quietly surrounded by family in a SNF?  Ideally this patient should be at home but sometimes the family just cannot provide the support and care in their home?  Is the only alternative an acute care hospital via 911 or Hospice?