Transition of Care to Skilled Nursing Facilities

Situation:

Transition of care to Skilled Nursing Facilities (SNF) is a living breathing paradox

Background:

Patients discharge from acute care hospitals to SNF’s regularly for rehabilitation or long term care.

Assessment:

SNF’s do not communicate electronically with acute care hospitals.

Hospitals send discharge packets that are close to the whole medical record which may cause follow up confusion.

The transfer process is messy and disjointed with little to no verbal communication between the SNF clinicians and Hospital clinicians.

SNF’s do not have pharmacies and radiology on site.

Patients have unrealistic carry over expectations from the hospital to the SNF regarding capabilities.

SNF’s are not as resourceful as acute care hospitals  and are much smaller in size.

Recommendation:

Research your SNF of choice prior to transfer.

Ask the hospital case manager/social worker  for more than one choice of SNF in our area.

Visit the website https://www.medicare.gov/nursinghomecompare/search.html Get the Medicare ratings of the SNF’s.

Advocate for yourself while at the SNF or appoint a capable health care proxy.

Communicate your personal goals of returning home ASAP and your expectations for the SNF.

Do as much as your body allows  for yourself to avoid learning helplessness.

Be nice to the staff, it makes everybody’s life easier.

 

 

 

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