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How to improve the transition between hospital and a skilled nursing facility

​Transitioning to a skilled nursing facility after dealing with the stress of a hospital stay can bring a period of unease for patients and their families, especially if they're not sure what to expect. Understanding the basic differences in these highly-specialized care centers can help ease discomfort and help patients successfully prepare for the benefits they will receive while staying in a skilled nursing facility.

Focus of Care

While each has specially-trained professionals and equipment designed to assist patients, the primary purpose of a hospital is dealing with acute care which is focused on diagnosis, treatment and cure. While hospitals can stabilize and begin a process of treatment with patients, they often lack the resources to deal with continuing functional improvement. That's where skilled nursing facilities step in to assist those patients who require rehabilitation, therapy or assistance with daily living activities.

"Family members and caregivers can play an important advocacy role for their loved ones during the transition to a skilled nursing facility," says a Nick Williams, Chief Operations Officer for PruittHealth, noting that clear communication can help both parties during a transition. "Asking for a record of medications a patient was taking in the hospital, as well as relaying information to skilled nursing staff about a patient's mobility, diet and procedures they are aware of is a crucial step in getting a patient settled in the fastest time possible."

Skilled nursing facilities are regulated and inspected by the state, and the staff to patient ratio is generally smaller than that of a hospital. The skilled services offered in a nursing facility are varied and could include wound care, intravenous medications, physical, speech or language therapy and round the clock physician care. Skilled nursing facilities are also required to have a transfer agreement in place in the event a resident needs to return to the hospital.

Length of Stay

While hospitals are equipped to handle a wide-range of medical conditions, stays are intended to be just long enough to discharge the patient to another level of care or to see them back home. When a stable patient requires extensive or ongoing therapy, such as after a stroke, a skilled nursing facility can provide targeted treatment and therapy that a patient can't access from home or another assisted-living facility. In fact, one in four Medicaid patients is discharged to a skilled nursing facility,1 but the length of stay in such a facility is also variable. Some patients may benefit from a short recovery stay involving therapy and rehabilitation which is tailored for their needs, but where the goal is for the patient to return home. Other patients will benefit from a host of the same services coupled with round the clock care for an extended period. Both options do not contain a time-limit as care is based on the needs of the individual.

When preparing to leave the hospital, a discharge planner will likely be assigned to work with a patient and their family to find the most suitable care for the patient. The Admissions Coordinator of a skilled nursing facility is responsible for coordinating the intake of a patient and filling out the necessary paperwork to admit a resident.

Daily Services

While there is some overlap regarding occupational, speech of other therapies, a skilled nursing facility builds upon the work started at the hospital and expands its services to include assistance with such daily living activities as being able to wash, dress, eat and safely navigate the basic mobility requirements of life. Targeted therapies are aimed at ensuring patients regain or maintain the maximum amount of independence that their conditions allow.

"For people who have experienced a serious medical event, daily living activities can present a frustrating challenge. Skilled nursing facility staff are highly-trained to help patients navigate both the physical and mental stress of mobility issues." Says Williams for PruittHealth, noting, "The care offered by facility staff extends beyond medical needs and addresses the patient's social needs as well to create a whole-person approach to care."

Knowing which activities and events supplement essential care can help reduce anxiety and stress for both patients and their families when transitioning to a skilled nursing facility. Good communication and the willingness to ask questions along the way can make for a successful move.

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