Hospital to Rehab/Skilled Nursing Facility: Steps Caregivers Need to Know

When a loved one is hospitalized, caregivers often face the question: ‘What happens next?’ In this episode of Take Care, Melody Mulaik shares her experience helping her 90-year-old mother transition from the hospital to a rehabilitation or skilled nursing facility.

Melody explains key steps caregivers should know, including Medicare’s ‘three-day hospital stay rule’, the role of hospital case managers, and how early communication with the care team can help make the transition smoother.

What You’ll Learn:

• Caregiving decisions after a hospital stay. Understanding the challenges of caring for aging parents and deciding between home care or rehabilitation services.
• Medicare rules for rehab coverage. Why the three-day hospital stay requirement and admission status matter for skilled nursing or rehab eligibility.
• Working with the hospital care team. How case managers, therapists, and caregivers help coordinate rehab placement and support recovery.

Timestamps:

• 00:00 – Melody shares her experience caring for her 90-year-old mother.
• 01:00 – Hospital admission and evaluating care options after discharge.
• 02:00 – Medicare’s three-day hospital stay rule for rehab coverage.
• 03:00 – The role of hospital case managers in coordinating rehab placement.
• 04:00 – Why communication with therapists and caregivers matters.
• 05:00 – Transitioning successfully to a rehab or skilled nursing facility.
• 06:00 – Encouragement for caregivers navigating similar situations.

If this episode helped you, share it with someone who may be caring for an aging loved one. Have questions or experiences to share? Leave us a comment on our website.

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Transcript

Melody 0:13

Hello everybody. Welcome to this episode of Take Care. You know, It's been an interesting couple of weeks for me. I don't know how many of you are navigating taking care of your parents, but I am in that position of taking care of my 90-year-old mother. She's actually lived with us for over 25 years, close to 30 years. We moved her and my dad in many years ago. And my dad unfortunately passed away 10 years ago this year. And mom's been with us during this time period. And up to this point she's been pretty healthy and been able to function a lot on her own. But more recently she's had some challenges with falls and other things, including a couple weeks ago, having to go into the hospital for RSV and having somebody that's older and then trying to make those determinations of what do you do for next steps of, do you come back home and do you get home health, or bring people in, or do you need to put them into a facility that enables them to get the additional care that they need? After a lot of evaluation and really looking at the options I made the decision to put her into a rehab situation, outpatient rehab. And it's been an interesting process'cause there's always a lot of things to learn. I have been in healthcare for over 30 years more like 35, 40 years. And in that time period, I've had a lot of opportunity to work directly in hospitals and physician offices. And dealing with skilled nursing and that whole aspect of healthcare is, I'll admit a somewhat newer thing for me. And so, there's a lot of things I'm learning in the process as we go through it. And some key things that I wanted to pass along to you in this session today was some of the things that I've learned in the last couple of episodes that we've had at the hospital and for long-term care, especially for an older person as it relates to Medicare. So, one of the things that you definitely want to make sure that you know is that in order for Medicare to pay for a rehab or skilled nursing stay, there's several criteria that come into play and you can really get into details and you can look on CMS's website and get that. But one of the key ones is that typically there has to be a three day stay at the hospital. Now that does include the day they're admitted.

2:30

So, the 72 hour rule really applies to before they're admitted into the hospital where the three day rule is on the backside. They need to have three days in the hospital itself, and that enables, that transition into that skilled nursing facility slash rehab. There's a lot of different ways they label that at that point. But one of the things that's really important too, is not just that coverage piece, but also working with your case manager and with the medical team at the hospital as well. Because it's really important that as you are thinking through, as an advocate for someone, your potential options, don't keep that to yourself. You want to share it with a case manager. One of the first things that I did when she got admitted was to ask to speak to the case manager so that I could let them know what we were evaluating. Because then they partner with you to say, okay, if this is what you're looking at, they give you a list of facilities. They can search it based on the zip code by where you live, and they provide that to you. And then they do the work for you where they will send the medical information over to the facilities to see if there's a match. And whether or not they can offer up a bed and offer up services, which is a really big help. So, that's something that they do. It's also really important that you let the caregivers within the hospital know especially such as physical therapy and occupational therapy and speech therapy to know what you're evaluating as well, because that may change how they document. It's not that they're taking care necessarily differently, but they know that it's its own system to navigate and that there's really key phrases and key words and key things that is important to communicate to a skilled nursing facility. And so they become your allies in the process to make sure that they're doing things and documenting things appropriately and addressing the things that they know those facilities are interested in. So, you don't find yourself in a situation where they go gee, if you had told me that I might not have said this or I would've said this. So again, it's not that we're asking or they're changing things in any inappropriate way, but they're just explaining things in a way that make it, I won't say easier, but facilitate that transfer process. So, if you have a loved one that is in the hospital and you're looking at utilizing outpatient rehab, which is a fancy way of saying, it feels like it's inpatient to the person that's there, but it's not the same level of service as say, inpatient rehab. So, if you're looking to do that transfer to that skilled nursing facility slash outpatient rehab, letting them know in the hospital as soon as possible, talking to the caregivers can help make it a smoother process. So, we were able to do a good transfer. We actually I'm very pleased with the place that my mother's at right now. It's clean. The staff is great. They have really good therapy equipment. They've got the full staff of the physical therapists, occupational therapists, speech therapists, respiratory therapists, you name it. And they're taking really good care of her, enabling her to get stronger so that then she can come back home, which is her goal, which is our goal as well. Navigating these types of things is challenging, and it's stressful when you're in that position as a caregiver. I just encourage you to take advantage of the staff that you have there at the hospital. Coordinate with your care manager and share any experiences that you've had because as you journey through life and as you address these kind of things, sometimes you don't know all the things that you need to know until you get put in that situation and you have to figure things out together. So, I hope this has been helpful for you. Maybe you've got a friend going through it and you need to share this with them, but I'd love to hear from you. Put in a question or comment on our website and share with your friends so that you can take care.