After an unexpected fall led to hip surgery, maybe your 85-year-old father thought he’d be back to his routine in no time. His doctor, however, says it’s not safe for him to discharge home. He’s still struggling with pain, walking and getting to the bathroom on his own.
For seniors barely recovering from illness or surgery, knowing where they need to turn to next can feel both daunting and urgent. Fortunately, skilled nursing care can provide the support needed for a safe recovery.
Here’s what to know about navigating short-term skilled nursing care, also referred to as skilled rehab, how to qualify for this care and how to have it covered by Medicare.
What Is Skilled Nursing Care?
Skilled nursing care is nursing or therapy services provided or overseen by licensed health care professionals. Skilled nursing care is provided in a variety of settings, sometimes called skilled nursing facilities, nursing homes or long-term term care facilities. However, when the care is provided for a short time, it is typically referred to as short-term rehab or skilled rehab.
Skilled nursing care services include:
— Medication management. This includes oral, IV or topical medication administration. Seniors are often battling chronic health conditions in addition to their short-term rehab condition and their pain. Combining medications requires a provider and pharmacist to oversee the medication interactions and a nurse to properly administer them.
— Nursing interventions. This may cover specialized care ranging from wound care and respiratory treatments to assisting with feeding tubes or administering insulin based on blood sugar levels.
— Therapy. Therapy may include physical therapy, occupational therapy and speech therapy. For example, physical therapy may be incorporated to help someone improve mobility after a knee replacement, occupational therapy may help an older adult with adaptive strategies for their daily activities like using a shower chair, and speech therapy may help a senior improve their swallowing after a recent surgery.
— Ongoing monitoring and evaluation. This could include services like lab draws to see if an antibiotic is effective in treating an infection.
— Other services and amenities. These aren’t exclusive to skilled nursing, but you’ll also receive services provided at lower levels of care. This may include help with daily hygiene, nutritious meals or social activities.
Skilled nursing facilities serve as an important bridge between hospital care settings and the home, says Ahzam Afzal, Chicago-based co-founder and CEO of Puzzle Healthcare, a post-acute readmission prevention company.
The goal of skilled nursing after a hospital stay, Afzal says, is to prevent hospital readmissions. This is most effective right after a senior is discharged from the hospital. Often, the services provided in skilled nursing facilities are hard to receive at home immediately after a hospital stay, and this option allows providers to take action before any issues escalate.
“These services provided directly at the facility ensures patients have the right therapy teams in place to help them achieve prior level of functioning in their daily living activities, which is critical to ensure patients don’t have any issues continuing their recovery when they go home,” he explains.
[READ: 13 Questions to Ask Before You Leave the Hospital]
What Qualifies a Patient for Skilled Nursing Care?
Seniors may need skilled nursing care in the form of short-term rehab after a recent illness, injury or surgery.
For seniors who require long-term nursing home or custodial care, make sure to research nursing home requirements. Medical requirements for this type of care are a little less rigid, but Medicare does not cover this type of care.
There are a few elements that go into how a senior qualifies for skilled nursing care, says Jessica Corona-Irwin, a Columbiana, Ohio-based nurse, certified dementia practitioner and certified support group facilitator at Remo Health, a virtual dementia care company. These include:
— Need for skilled care. Seniors must have a need for skilled nursing services that cannot be provided at a lower level of care. “The goal is to restore their baseline ability, or to achieve maximum possible improvement,” Corona-Irwin says.
— Potential for improvement. There should be an expectation of improvement in the senior’s condition through the rehab services, Corona-Irwin says. If skilled rehab would not improve their condition, the senior might consider other options, such as long-term custodial care or palliative care.
— Completed interdisciplinary assessment. An interdisciplinary team of providers, nurses, social workers and therapists will evaluate the senior’s need for skilled rehab. They may base the assessment on the senior’s current physical and mental health, support they currently have available at home and their recovery goals.
[Related:How to Advocate for an Older Loved One in the ER or Hospital]
What Qualifies as Skilled Nursing Care for Medicare?
Medicare Part A, or hospital insurance, covers up to 100 days of skilled nursing care in each benefit period when the care is for short-term rehab.
Here’s what Medicare requires:
— You recently had a qualifying hospital stay. This means you’ve been admitted to a hospital under inpatient status for at least three full days, not counting the day of discharge.
— You have a qualifying medical condition. You must need skilled nursing care due to a condition that was addressed during your hospital stay. However, that skilled nursing care doesn’t need to relate to the main reason for admission.
— You receive the skilled nursing care within a month. You need to be admitted to a skilled nursing facility within 30 days for care related to your hospital stay. “If you miss that window, you’re not covered,” says Alfred Polizzotto III, the managing partner of the law firm of Polizzotto & Polizzotto LLC in Brooklyn, New York.
— You must have days left in your benefit period to use. A benefit period starts the day you are admitted to a hospital or skilled nursing facility. A benefit period ends once you have been discharged and had 60 consecutive days without receiving inpatient care.
[READ: How Do You Apply for Medicare?]
Medicare limits and Medigap coverage
According to Genworth Financial’s 2023 Cost of Care Survey, the cost for a room in a skilled nursing facility is around $300 per day. Medicare coverage varies depending on how long you have been receiving skilled nursing care.
— Days 1-20: Your copay is $0 if you meet the above qualifications.
— Days 21-100: Your copay is $204 per day if you meet the above qualifications.
— Day 101 and beyond: You are responsible for all Medicare Part A costs related to your skilled nursing care.
A common mistake is when families don’t realize that Medicare only covers short-term skilled rehab, Polizzotto says.
“Another catch is that Medicare doesn’t cover long-term care or help with daily activities like bathing or dressing. If your loved one just needs help getting through the day and isn’t in skilled nursing anymore, you’re on your own for that,” he adds.
Polizzotto advises his clients to get a Medigap plan to help cover quickly multiplying coinsurance costs.
“Basically, wherever there’s a ‘gap’ in the Medicare plan, the Medigap plan covers those costs. Expenses like deductibles and copayments, which can really add up, are more taken care of,” he notes.
It is an additional payment, but Polizzotto says it can help with your peace of mind to know you have more of a financial cushion.
The Medigap open enrollment period lasts six months, starting on the first day of the month you turn 65 and signed up for Medicare Part B. If you’re past your open enrollment period, you may still be eligible for a Medigap policy, but it usually requires medical underwriting.
Explore Top-Rated Skilled Nursing Facilities With U.S. News & World Report
If your loved one may need skilled nursing care, start researching options and seeking recommendations from their medical providers and your community as early as possible. The more information you gather up front, the better prepared you’ll be to make informed choices and plan financially.
To find the best skilled nursing facilities near you, check out the U.S. News & World Report top-rated nursing homes. In 2024, U.S. News evaluated more than 15,000 facilities throughout the country and rated most of them on short-term rehabilitation and long-term care. Look for the “Short-Term Rehabilitation Rating” label when researching skilled nursing and short-term rehab facilities.
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What Qualifies a Patient for Skilled Nursing Care originally appeared on usnews.com
