What skilled nursing care includes
Skilled care is nursing or therapy that must be performed by, or under the supervision of, qualified professionals. Depending on your parents’ needs, it may include skilled nursing, physical therapy, occupational therapy, speech-language therapy, medications, medical supplies, dietary counseling, or other services included in a Medicare-covered SNF stay.
The purpose is usually rehabilitation or management of a medical condition for a limited period. Medicare does not cover a long-term stay when the person needs only custodial help such as bathing, dressing, eating, or supervision. That's going to fall under assisted living (AL, meaning a facility away from home) or bringing caregivers into your parents' home. If your parent qualifies for VA health, I'm told that it is really strong in funding this kind of in-home support.
This content is targeted at adult children who are not the daily caregivers for their parents, so it is likely that you are also not available to be their caregivers during the SNF time period. Consider keeping third-party eyes on them, even if it's not you. The care at the SNF will be less intense than at a hospital, and your parent will be coming down from the adrenaline and fast pace of the hospital. Whether it's you or another representative of the family (including a paid caregiver), it can be useful to have someone visiting your parent while they are away from home. This can also ease the path to any extra care they'll get when they come home. The SNF time and supervision gives you or a caregiver time to learn what support your parent will continue to need. This SNF visitor may be a certified nursing assistant (CNA) you hire to help them at home or it could just be a friend or companion or grandchild who offers a second set of eyes and ears to transfer knowledge between locations.
Confirm Medicare coverage before transfer
Under Original Medicare, SNF coverage usually requires:
- Medicare Part A coverage and available benefit days;
- a medically necessary inpatient hospital stay of at least three consecutive days, not counting the day of discharge;
- entry into a Medicare-certified SNF generally within 30 days after leaving the hospital;
- a clinician's determination that daily skilled nursing or therapy is needed; and
- skilled services related to a condition treated during the qualifying hospital stay, or a condition that began during covered SNF care.
With a Medicare Advantage program, the requirements are usually less strict for qualifying for SNF coverage. On the other hand, the SNF’s that will accept your parents are much more restricted. The facilities are reimbursed less by Medicare Advantage plans, so not all SNF’s that take Original Medicare will choose to take all Medicare Advantage plans and they may try to discharge your parents sooner.
As noted in the hospitalization section, time in an emergency department or under outpatient observation at a hospital generally does not count toward the three-day inpatient requirement with Original Medicare, even when the person stays overnight, as mentioned related to status in the Hospitalizations section. Medicare Advantage plans may waive the 3-day rule and may also have other requirements that differ from Original Medicare.
Medicare's SNF benefit is limited and continued coverage depends on the person still meeting the requirements for daily skilled care. It is not a guarantee of 100 covered days. Current deductibles and daily coinsurance can change each year; check the person's plan and Medicare's current cost information, and consider these possible needs when choosing a Medicare plan in October or November of each year.
Compare the facilities that can meet the need
Use Medicare.gov's Care Compare as a starting point, then visit when possible. Ask about:
- staffing levels, turnover, recent inspections, complaints, and short-stay quality measures;
- experience with the person's condition and the nursing or therapy services required;
- how often therapy is offered and how progress toward the person's goals is measured;
- medication management and access to physicians, nurse practitioners, pharmacies, and emergency care;
- transportation for dialysis, specialists, or other outside appointments;
- infection prevention, meals, language access, hearing or vision accommodations, and cognitive support;
- room arrangements, visiting, transportation, and distance from the people the older adult wants involved; and
- what happens if coverage ends before the person is ready to return home.
Quality ratings summarize selected measures; they do not replace a visit, current inspection information, and questions about the care this person needs.
Set goals and plan for discharge from the beginning
At admission, share an accurate medication list, allergies, health history, advance directive, and the person's usual level of mobility and daily function. Make sure the care plan reflects your parent's own goals, such as walking safely to the bathroom, managing stairs, or transferring into a car.
Ask when the first care-plan meeting will occur, how your parent and chosen family members can participate, how progress will be reported, and who to contact with concerns. Start planning for the next setting early, including caregiver training, home safety, equipment, prescriptions, follow-up care, and transportation.
If coverage or care is a concern
Medicare will communicate coverage updates to your parents, so try to get access to those messages. There is a path to getting access to your parents’ Medicare information legally (and not just using your parents’ login) described on the Medicare page. Read every coverage notice promptly. If the facility or plan says Medicare-covered services will end, the notice should explain the appeal process and deadline. An appeal can get your parents extra time, but you’ll only have a short window to submit. Contact the plan, Medicare, or SHIP for benefits help.
Take any care concerns to someone on-site, starting with the nurse, administrator, or care-plan team. A Long-Term Care Ombudsman can help with residents' rights and unresolved concerns. Report immediate danger or a medical emergency to 911; suspected abuse or neglect can also be reported to the appropriate state agency or Adult Protective Services.
While there are true reasons to be concerned, know also that there are some common complaints from patients that are not related to actual neglect. The phrase "unreliable narrator" may explain this well. Your parent may not realize that their discomfort is being handled as well as possible, or that their understanding of a situation is incorrect. Especially if you are at a distance, you may need to listen to multiple accounts to determine the reality of a complaint. Focus your energy on what to do next for your parents.
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Look into home safety.