By Jennifer Beach, LSW, MA, C-SWCM
Scott is in his upper 60s and was diagnosed with Progressive MS (Multiple Sclerosis ) about eight years ago. Recently, he fell in his home and broke his femur. 911 was called, he was admitted to the hospital and had to have a procedure to set the broken bone. His leg would need to be immobilized to heal. The hospital team had done their job and now it was time for Scott to go to a skilled nursing facility for rehabilitation.
Prior to this incident, Scott had two caregivers who worked several hours daily at his home to help him with his daily routine. At this time, with his leg injury, he would require 24-hour care and support to assist with all aspects of the day, including the need for caregivers to help with hygiene, dressing, bathing, getting in and out of bed, preparing meals and dispensing his medication, along with the rehabilitation. Rehab is the physical and occupational therapy to help maintain muscle strength, range of motion, balance, endurance and to help the patient learn to be as independent as possible, given his new limitations.
Scott was sent to a facility relatively close to his home. He doesn’t recall who selected the facility or many of the details of the past couple of days. Between the trauma of the fall, surgery, anesthesia, pain medication and his MS, it’s understandable why he may have forgotten many of the details. Scott has a brother who lives out of state. He and neighbors who have been a big help to Scott over the past eight years were contacted by the hospital upon admissions. Scott is in the process of getting his legal documents in place, but things were not completed at the time (meaning he did not have a Power of Attorney). Scott appeared to be cognizant, answering questions while in the hospital, so was considered to have capacity to make his own decisions. The case manager talked directly with Scott about his discharge, including picking a skilled rehab to go to.
Scott was notified he would be discharged on a Friday evening. The transportation (ambulette) service his insurance covered would arrive at 5 p.m. to take him on a stretcher to the rehabilitation facility. Transportation finally arrived at 12:10 a.m. and dropped Scott off at the facility around 12:40 a.m. on that early Saturday morning. It was very painful for Scott when he was moved off the transport stretcher at the facility, which did not receive the correct paperwork from the hospital. They did not realize he had a catheter, the start of a bed sore, or what time he took his last dose of medication.
There were only two aides available and one nurse working on his wing at that hour. They knew nothing about Scott, other than they were told a new admission was scheduled at some point on Friday night. The nurse would need to call the hospital and get his medication orders. Over the next 72 hours the facility doctor, physical, occupational and speech therapists would assess his needs, write medication orders and a plan of care. In the meantime, his medications would need to be called into the facility pharmacy and delivered. Once the nurse obtained more information from the hospital, she could administer some of the medication if they were available within the facility; the rest would have to wait until delivered from the pharmacy. This could take up to 24 hours. In the meantime, Scott was thirsty, in pain and uncomfortable.
Scott’s case is far from uncommon. Here are several things to consider if you or your loved one need to transition to a rehabilitation facility:
- If possible, have someone at both the hospital and the rehab facility to help advocate, ask questions, review details of care, and be an extra set of eyes and ears.
- Meet the hospital case manager (sometimes called Discharge Planner/Social Worker) as soon as possible upon admission to the hospital. This will be an important contact person to ask questions and to begin to discuss the need for potential rehabilitation facilities.
- Learn about the individual’s insurance coverage, what facilities accept the insurance and can take new patients.
- Help with selection process of a rehabilitation facility. (This is discussed in other blog articles in more detail).
- Be prepared to wait. Transportation from the hospital to a facility may be scheduled but often can be much later than scheduled times. Be sure the patient has eaten, is clean, has water, has taken medications and when the last dose of medication(s) was administered.
- If the individual suffers with pain, ask the medical providers if any pain medication can be given just prior to being transported to the facility.
Scott ended up getting pain medication around 4 a.m. and the rest of his medications around 7 p.m. that evening. Unfortunately, it was a long 24 hours for Scott but slowly, things were put in place and started to improve. Having someone with Scott to help ask questions, understand the process and advocate may have improved his transition.
Original Article: https://www.northeastohioboomer.com/blogs/what-to-know-transitioning-from-hospital-to-skilled-nursing-facility/