How to Choose a Skilled Nursing Facility

Introduction

"The hospital says my mom needs a skilled nursing facility and wants us to choose one. How am I supposed to do that by tomorrow?"

Choosing a skilled nursing facility would be easier if families had several days to research facilities, make phone calls, visit their leading choices, and carefully compare options.

Hospital discharge planning often doesn't provide that luxury. Your loved one may be medically ready to leave the hospital within a day or two, and you may have work, family responsibilities, or other demands on your time.

Before doing anything else, ask two questions:

• When is my loved one expected to leave the hospital?
• How much time can I realistically devote to helping choose a facility before then?

You do not need to conduct an exhaustive search. Your goal is to perform enough due diligence to make a reasonable decision among the facilities that can actually care for your loved one.

Understand the Referral and Selection Process

Choosing a skilled nursing facility is usually an iterative process involving the patient or family, the hospital case manager, potential facilities, and the patient's insurance.

The exact process varies among hospitals, but it often works something like this:

• The healthcare team determines that skilled nursing facility care should be considered.
• The case manager identifies facilities that may be able to meet the patient's needs and participate with the patient's insurance.
• The patient or medical decision maker may be asked to identify several facilities they would be willing to consider.
• Referrals are sent to those facilities, often electronically.
• The facilities review the referral and determine whether they can meet the patient's needs and accept the patient.
• Some facilities may accept, some may decline, and others may request additional information before making a decision.
• The patient or medical decision maker then makes a final choice among the facilities that are actually available and able to accept the patient.

These steps may happen quickly and may overlap. You may be considering facilities at the same time the case manager is sending referrals and facilities are reviewing them.

The important thing to understand is that identifying a facility you would consider is not necessarily the same thing as making your final choice.

Selecting several possibilities early can allow the referral process to move forward while you continue gathering information.

Find Out Where You Are in the Process

Before spending time researching facilities, ask your case manager where things stand.

Useful questions include:

• Have referrals been sent yet?
• Which facilities are reviewing the referral?
• Has anyone accepted my loved one?
• Has anyone declined?
• Are any facilities requesting additional information?
• Am I choosing facilities for you to contact, or am I choosing among facilities that have already said they can accept my loved one?

That last distinction can save you considerable time.

There is little value in spending an hour carefully researching a facility only to learn that it doesn't accept your loved one's insurance, doesn't have a bed, or cannot meet their care needs.

Your Real Choices May Be a Much Shorter List

A hospital may initially provide information about many skilled nursing facilities, but not all of them will necessarily be realistic options.

A potential facility needs to consider several things before accepting a patient, including:

• Whether it can meet the patient's clinical and care needs.
• Whether it accepts the patient's insurance or payment source.
• Whether it has an appropriate bed available.
• Whether it has the staff, equipment, and services necessary to care for the patient.

Facilities may decline referrals for any of these reasons.

Once facilities begin responding, a long list may quickly become two or three realistic choices.

That's when your limited research time becomes most valuable.

If Time Is Short, Start With Basic Due Diligence

If discharge is approaching quickly, focus on information you can obtain without making multiple site visits.

Start with Medicare's Care Compare website. Medicare provides an overall rating from one to five stars for Medicare-certified nursing homes, along with separate information about:

• Health inspections.
• Staffing.
• Quality measures.

Don't look only at the overall number of stars. Look at the individual categories as well.

Next, check whether there are significant regulatory concerns. State regulatory agencies inspect nursing homes and may publish information about deficiencies, complaints, enforcement actions, sanctions, or facilities receiving enhanced oversight.

Medicare also identifies some persistently poor-performing nursing homes through its Special Focus Facility program.

You don't need to become an expert on nursing-home regulation. You're looking for information that should either reassure you or prompt additional questions.

Look for Patterns, Not Perfection

Every facility can have deficiencies, complaints, or areas where its performance could improve.

Look for patterns rather than allowing one isolated finding to make the entire decision.

Consider:

• Are there repeated problems on health inspections?
• Are there serious deficiencies involving resident health or safety?
• How does staffing compare with your other choices?
• How does the facility perform on measures involving short-stay residents?
• Is the facility currently receiving increased regulatory scrutiny?

A poor finding doesn't automatically mean you should reject a facility, just as a five-star rating doesn't guarantee that your loved one will have an excellent experience.

Ratings and regulatory information are tools for narrowing your choices and identifying questions. They aren't substitutes for judgment.

Make Sure the Facility Fits Your Loved One

Quality ratings matter, but so does the facility's ability to care for your particular loved one.

Make sure you understand why skilled nursing facility care is being recommended and what your loved one will need.

Important needs might include:

• Physical or occupational therapy.
• Skilled nursing care.
• Wound care.
• Oxygen or respiratory care.
• Dialysis transportation or coordination.
• Behavioral health support.
• Other specialized care.

A highly rated facility that cannot effectively meet your loved one's particular needs is not your best choice.

Location Matters

Once you've narrowed the choices to facilities that can meet your loved one's needs and don't raise significant concerns, consider location.

A facility close to family can make it easier to visit, participate in care planning, communicate with staff, bring personal items, and prepare for the patient's eventual return home.

A highly rated facility an hour away may not necessarily be a better choice than a good facility ten minutes away.

Think realistically about how often family members will actually be able to visit, rather than how often everyone hopes they will visit.

If You Have More Time, Use It

If the discharge timeline allows, go beyond the basic screening.

Call one or two of your leading choices and ask about the issues most important to your loved one's care.

If possible, visit your leading facility.

During a visit, don't focus primarily on the lobby, furniture, or age of the building. Pay attention to the care environment:

• How do staff interact with residents?
• Do residents appear clean and cared for?
• How do staff respond when residents need assistance?
• Does the environment seem reasonably organized and clean?
• Are staff willing to answer your questions?

A visit can provide valuable information, but you haven't failed your loved one if circumstances don't allow you to visit every facility before making a decision.

Confirm Insurance and Coverage

Before making the final choice, make sure the facility accepts your loved one's insurance or other payment source.

If your loved one has Original Medicare, confirm that the facility is Medicare-certified and that the requirements for skilled nursing facility coverage have been met.

If your loved one has a Medicare Advantage plan or other private insurance, confirm that the facility participates with the plan and that any required insurance authorization has been obtained.

Ask what expenses your loved one may be responsible for paying.

The hospital case manager and skilled nursing facility should be able to help clarify these questions.

Remember That This Is Usually a Temporary Transition

For many patients, a skilled nursing facility is a temporary stop between the hospital and home.

Ask what your loved one needs to accomplish during the skilled nursing facility stay and what will need to happen before returning home.

If family members will be expected to provide care afterward, be realistic about what they can actually provide.

Work schedules, family responsibilities, travel distance, physical limitations, and the amount of care the patient will need all matter.

A plan that depends on family members providing more care than they can realistically sustain is unlikely to work well for either the patient or the caregiver.

If You Only Have an Hour

Sometimes that's the reality.

If you have only a short amount of time and several facilities have accepted your loved one, focus on:

• Can each facility meet my loved one's specific needs?
• Is insurance coverage confirmed?
• What does Medicare Care Compare show?
• Are there significant regulatory concerns?
• Which location is realistic for family involvement?
• Is there anything about one of these facilities that requires a follow-up question before we decide?

Then make the best decision you can with the information available.

The goal is not a perfect investigation. It is reasonable due diligence within the time you actually have.

How HNav Can Help

Choosing a skilled nursing facility can feel overwhelming, particularly when the hospital needs a decision quickly.

At HNav, we help patients and families understand where they are in the referral process, identify their realistic options, evaluate publicly available quality information, and focus their limited time on the questions that matter most.

Our goal is to help you make an informed decision without turning an already stressful hospital discharge into another full-time job.