Senior Care Focus

Leaving Hospital, Going to a Skilled Nursing Home: What to Expect

Admitting yourself or someone you love to a skilled nursing home for rehabilitation or long-term care is something that we may have to do and not what we may want to do. As we age, the risk increases for a health accident even if we are careful and healthy. “Unfortunately, not all of the care we will need can be provided in a hospital or at a rehab specialty center. Some of us will need to go to a skilled nursing home,” says Mr. John E. Kasarda, Administrator of Little Brook Nursing Home in Califon, NJ.

Near the end of your or your loved one’s hospital stay, you will be contacted by the Discharge Planner of the hospital to discuss the alternatives for continued care since you or your loved one may no longer meet the criteria for a continuing hospital stay. Once a patient is stable they must transfer to another level of nursing care.

The hospital’s Interdisciplinary Care Team will assess the patient’s care needs based on the acuteness of their condition and the monitoring required for the patient, the patient’s rehabilitation potential, the ability of the patient or their family’s ability to care for the patient, and the nature of the home environment that might support the patient. In all cases, the goal is to establish a safe discharge plan that meets the needs of the patient.

For the aged and for people with multiple disease states the recommendation may be for the patient to be admitted to a long-term care facility (a skilled nursing home) that provides skilled care. While the hospital’s Discharge Planner may provide a list of skilled nursing homes in the area, you should ask your friends, family, doctors, pastors and parishioners for a referral to a skilled nursing home with which they have had good experiences. It’s recommended that you take the time to visit at least three skilled nursing homes for the following reasons:

  1. Skilled Staff: Do they have the certified staff to provide the skilled services required? Is the staff responsive and caring?
  2. Environment: Find out if the environment is conducive to your loved one’s needs, safety, health and comfort levels.
  3. Cleanliness: Go and observe residents in the skilled nursing home. Are they clean and dressed nicely? Does the facility smell pleasant?
  4. Bed availability: Some skilled nursing homes have single bed rooms, double bed rooms, and, rarely, 3+ bed rooms, and
  5. Referrals: Talk to other residents’ family members if present as another referral source. What do they like and dislike?

For a more complete list, print the CALASH checklist at:

“Don’t be pressured to follow a hospital’s recommendation because ‘that’s where everyone goes’,” says Mr. Kasarda, “because you have a choice and the right to decide where you want to live and be cared for.”

After you make the selection, the Discharge Planner will check for bed availability at that skilled nursing home. The skilled nursing home may send out their nurse liaison to the hospital to assess the patient and make sure that they can provide the care and that they have the appropriate equipment for the patient. Also, they may seek additional information to verify that the patient has met Medicare criteria for a skilled rehabilitation stay and to obtain information to verify the payer source. This information is then passed on to the skilled nursing home’s Admissions Coordinator to review.

Once confirmed that the skilled nursing home will accept the patient, a Discharge Planner is contacted. The Discharge Planner will obtain the necessary physician orders to discharge the patient to the skilled nursing home and make transportation arrangements.

As a courtesy to the skilled nursing home, sometimes the Discharge Planner will fax the orders to the Admissions Coordinator so the receiving nurse can verify the equipment needed and order the medications required for the patient. Otherwise, the orders go with the patient to the skilled nursing home.

Before receiving the patient into the skilled nursing home, the Admissions Coordinator will verify the payer source. If the payer source is traditional Medicare they will verify the days available that Medicare will pay for. If an HMO is the payer source they will obtain required authorization, level of care and the days authorized to provide care. The Admissions Coordinator will disseminate all the hospital information to the Interdisciplinary Team of the skilled nursing home to prepare to receive the patient. By the time the patient arrives at the skilled nursing home the room should be ready with all of the necessary equipment. The Admissions Coordinator will have an agreement ready for the patient or the responsible party to review and sign. Once in the skilled nursing home, the patient is referred to as a “Resident”. The skilled nursing home is a different environment. It’s not a hospital, but should feel more like a home for a person requiring skilled nursing care.

“A senior’s golden years should be about living in peace, happiness, dignity, comfort, safety and good health. Your loved one deserves skilled nursing care that is both excellent and comprehensive!,” says Mr. Kasarda.


Editor: Dr. JP Hampilos of Senior Care Focus, LBHI; Excerpts from an interview with John E. Kasarda, Administrator, Little Brook Nursing and Convalescent Home on Tammy Gonzales’ 2005 adapted article entitled “Leaving the Hospital, Going to the Nursing Home”

Senior Care Focus, Issue No. 17.1

© 2018 Little Brook Home, Inc.