Skilled Nursing Facility
This week we’re going to dissect Skilled Nursing Facilities (SNFs): what they are and who needs them. A history of these facilities goes back to the early colonial settlers of the United States in the forms of an English almshouse. These houses were typically dedicated to a certain location (i.e. town or village) and provided meals and housing to persons who were unable to provide for themselves such as older adults, orphans, and widows. In the United States these evolved during the Great Depression and again after World War II to become places that could provide nursing care to older adults. An interesting side note - the oldest currently operating almshouse is the Hospital of St Cross in Winchester, England and it was founded in the 1130s!
A modern SNF is a residential care facility that provides services to those who need rehabilitation, specifically a type of rehab called subacute rehab (SAR), and those that need long-term care (LTC). Some will also have a memory care unit (MCU), but whether that service is provided depends on the facility.
Subacute rehab is commonly needed for older adults after a hospitalization. During a hospital stay, older adults can lose a substantial amount of muscle mass which can make it challenging to go home and do the day-to-day activities needed to live and thrive. Subacute rehab is the bridge to help people reach that goal of going home and sometimes to have that hard realization and discussion that a person can no longer safely care for themselves at home. Subacute rehab typically involves two hours of therapy per day, usually a mix of physical therapy, occupational therapy, and speech therapy. Medicare part A covers twenty days per calendar year in rehab, and 80% of the fee between days 21-100, and after 100 days everything is out of pocket. Medicare part B covers physician visits during this time, as geriatricians such as myself round and perform check-ups on patients in subacute rehab. Once a person reaches certain milestones according to the therapists, they are discharged from therapy services, usually back home but sometimes to an assisted living or to long-term care.
Long-term care is another service provided by SNFs, and to qualify for LTC a person must be deficient in two of the five Activities of Daily Living (ADLs). These include bathing, transferring, toileting, dressing, and eating. In my experience it is usually the loss of toileting that families and caregivers have the most challenging time with as clean-up and peri-care of a loved one feels very invasive and daunting. The loss of these ADLs must be due to a physical or cognitive impairment as loss due to mental illness may not always be covered. LTC is covered by Medicaid, but not Medicare; and most of the time expenses are taken out of pocket while a person “spends down” to qualify for Medicaid. Once a person moves into a SNF for LTC it is usually for life, but in rare cases a person will be able to move back home with family or to an assisted living. People that live in LTC wings of SNFs still can get therapy with physical therapy, occupational therapy, and speech therapy but usually in the form of “restorative” therapy where the goal is to maintain strength and function rather than to gain strength and function that occurs in subacute rehab.
If a SNF has a memory care unit, it is a locked wing that houses persons with dementia who have wandering tendencies or who become agitated or aggressive easily. The functional ability of these persons is widely variable but the common factor is dementia that is dangerous to self and others, so the staff are usually trained, formally and informally, to assist patients who have experienced this cognitive loss. MCUs provide variable services depending on if they are associated with a SNF or assisted living facility (ALF) which does not provide or have access to 24/7 nursing care.
Many, if not most, adults in the United States of America have a goal of aging independently and at home, but the ugly reality is that about 70% of those who reach age 65 will need long-term care services in our lifetime. To prevent that, we must be diligent in maintaining or starting a healthy lifestyle and communicating What Matters to those important to us.
Key Points:
Skilled Nursing Facilities most often provide two services, subacute rehab and long-term care
Subacute rehab is covered by Medicare part A, and long-term care is covered by Medicaid
70% of adults 65 or older will need long-term care services in their lifetime
