Issue # 7 January 2024
In This Issue: Hospital Discharges, Part 3, Choosing a Facility
Dear Reader,
Leaving the Hospital: Choosing the Right Facility
The question of how to ease the transition of a loved one out of the hospital is a difficult one—as difficult as any decision a caregiver must make—which is why I am devoting three newsletters to it. In my first installment, I looked at various steps that you, as a family member or friend, can take to make the patient’s discharge smoother and safer. In the second installment, I discussed the levels of care available if the patient is not ready to go home.
In this third and final installment, I conclude with advice on how—once you have understood the level of care being recommended—to pick a specific facility. Not all facilities are created equal. With that in mind, here are some considerations:
Location: Most people tend to pick a facility based on location. This is understandable: you want to be able to visit your loved one. Visiting your loved one in a facility is not only a good deed; it keeps them safe. Too many important care details and medical issues fall through the cracks when there is not someone at the bedside watching and speaking up. Indeed, to track the care your loved one is getting, you have to be able to visit. No matter how beautiful a facility is, no matter how stellar its reputation is, if it’s 100 miles away, you won’t be able to ensure they are being treated well unless you rent an apartment nearby. At the same time, choosing a facility simply because it’s a quick walk or drive from family, however tempting, can be a mistake.
Staffing: There are two facets to consider when it comes to staffing: the robustness of the staffing, and the expertise of the professionals on that staff.
First, try to get a handle on the amount of staff.
You can ask a facility for their staffing ratios, but this is a hot-button item, and sometimes you will get vague answers. The numbers given verbally can be misleading because there are different ways to calculate the ratios. If you want to try, ask for the ratio of nurses (RNs and LPNs) to patients and for the ratio of aides to patients on the unit where your loved one will be. Ask what the ratios are during the day and night shifts. Ask about staff turnover—less turnover is better. If a place has trouble keeping staff, it may be a red flag. (But keep in mind that everyone struggled to keep staff during the pandemic). Ask a staff member how often they “work short” (code for less staff here than there should be).
Second, ask about the staff’s training and expertise.
For nursing staff, find out if they are mostly RNs (registered nurses), or mostly LPNs (licensed practical nurses). RNs have more education and are better able to assess complex medical conditions. Ask if the nurses have any additional certifications like CRRN (certified rehabilitation RN) or Geriatrics.
Ask about the medical team. Will your loved one mainly be seen by a nurse practitioner (NP)? How often does the MD come to the building? How often does he or she see each patient? Is the MD a geriatrician? Do any specialists come to the facility? If so, how often are the specialists there?
Dig into rehab. Do the PTs and OTs, (physical and occupational therapists) have additional training, such as neuro rehab? Are most of the staff made up of new graduates? Inquire about the frequency of rehab service availability. Some places have only a skeleton crew on one day over the weekend. Also, if your loved one has a swallowing or language problem, ask how often speech therapy is available. Some places struggle to get a speech therapist more than once a week.
Special needs: Think about the special needs of your loved one. Does she need kosher meals? Is he on dialysis? What about wound care—is there onsite access to a wound specialist nurse or physician? Does she need a special bed? Special beds can be tricky, particularly when your loved one needs something expensive like an Envela bed. Ask questions and listen carefully to the responses. Facilities will often say that they will assess and provide what is needed. If there is something specific you think is needed, get an agreement upfront.
Physical Space and Happiness: You won’t always be able to tour facilities; there just might not be time. But, if possible, take a tour; it helps. And while on your tour, make sure to look at the people. Don’t be distracted by the chandelier, velvet lobby couches, or the nice air freshener they use. Look at the faces of patients and staff. You will see on their faces if they are happy or if they are stressed. If you can, walk around the specific unit where your loved one might end up. Also, check out the gym. If you’re visiting a rehab facility, always look at the gym! Are people having fun there, working hard with hands-on staff? Or is there just a couple of people sitting in wheelchairs tossing a balloon and looking miserable? Real rehabilitation looks like real rehabilitation.
Finally, everyone can do the following even from many miles away:
Find the hard data: I recommend people go to https://www.medicare.gov/care-compare/ ,or go to Google and type in “nursing home compare.” Medicare’s data is always a bit old—it’s not this month’s data. But it’s still useful. Look at the ratings (the “stars”) and dig into the staffing ratios and return-to-hospital rates and anything else you are interested in knowing. Don’t let tiny differences sway you. Instead, lump places into broad categories like acceptable, unacceptable, and maybe. The hospital discharge planner will want you to provide several options in case your facility of choice doesn’t have a bed or won’t accept your loved one.
Check the places you are considering with people who have been around: Anyone who has lived in an area for thirty years has heard things about the nursing homes and rehab facilities. Places do have reputations. Take what you hear (or read on sites like Yelp) with a grain of salt. Reputation can be reassuring—or it can make you question your decision.
The choice of the next facility matters.
One of the most common calls I get is from someone unhappy with the facility their loved one ended up in. Frequently the family felt rushed to decide and didn’t know what to ask. Often, they feel lied to or misled. They then hire me to get their loved one out, or at a minimum, make things better now.
For a client whose family desperately wanted to change facilities, despite multiple efforts to change to a different facility, he was stuck until he was sick enough to need readmission to the hospital. At the hospital, the family then refused to allow him to return to the place he’d been. They chose a much better place this time and he was then able to make progress.
Choose the facility after the hospital as carefully as you can because it is hard to change. People sometimes blame themselves, but it is the system that makes it hard to change facilities to another one at the same level.
Crazy? You bet. But that’s the system we have. And the better you understand it, the better it will be for your loved one.
Email me with your questions, comments, or subscription requests at gm@mymdadvisor.com. I’d love to hear from you.
Warmly,
Gerda Maissel, MD, BCPA
Dr. Gerda Maissel, MD CPE, BCPA
Dr. Maissel is a Board-Certified Physical Medicine
and Rehabilitation physician
and a Board-Certified Patient Advocate
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