Leaving the Skilled Nursing Facility:
A Guide for
If a patient is unable to return home,
where do they go? How will they pay for their care? Who will make the
Increasingly, hospitals are places for only acute
care, such as major surgery, intensive care or comprehensive testing and
immediate treatment for a serious illness. Once the crisis has passed,
the patient is often transferred to a Skilled Nursing facility (SNF).
These facilities are able to administer medications and provide
intensive therapy to get patients back on their feet.
When the medical personnel at the SNF have
determined that a patient no longer needs that level of treatment or is
not responding further, the SNF will notify the patient and family that
the patient will be discharged.
What should you do if you know that you are not able
to take care of your husband when he gets home, or if you’re afraid that
your mother can’t take care of herself? What should you be thinking
about, and what decisions do you need to make?
1. Is the patient really ready to leave?
The SNF is required to give families at least three
days’ notice, in writing, before a patient is discharged. If you believe
the patient would benefit from staying longer, you can file an appeal
with Medicare asking that they continue to pay for SNF care. The
discharge form should include the phone number you can call to file this
appeal. If it does not, ask the SNF Discharge Planner for this
If you agree that the patient will no longer require
that level of care but you need time to make arrangements, ask the
Discharge Planner if the patient can stay for a few days on a private
2. Can I get some help to take care of the
patient at home?
There are many “non-medical” home care agencies that
can provide aides to assist with bathing, dressing and transferring.
They can also help with cooking, light housekeeping and transportation.
Aides can be provided for a few hours or for 24-hour care.
Some agencies will bill a long-term care insurance
company directly, and others accept payments from the Arizona Long Term
Care System (ALTCS, which is the Medicaid program in Arizona) if the
patient is otherwise eligible. Look under “home care agencies” on the
internet or in the Yellow Pages, or the Discharge Planner may have some
recommendations. Also, more ALTCS
information is available on this website.
Some non-profit agencies can also provide a few
hours of care, respite for family caregivers, or meal preparation for
little or no cost. Examples in the Phoenix area include Duet (www.duetaz.org,
602-274-5022) or the Area Agency on Aging (www.aaaphx.org,
There are also agencies that provide home medical
care, such as administering intravenous medications, and physical,
occupational or respiratory therapy. You can find these under “medical
home care.” The Discharge Planner or home care agency may also have some
recommendations. If your doctor has ordered medical care at home, he may
select the provider or make a recommendation. To the extent that this
care is consistent with your doctor’s order, it is likely that the cost
would be covered by Medicare Part A or B.
3. If the patient can’t go home, where can she go?
There is a wide variety of residential care
facilities in Arizona. These are some of the terms you will hear:
Independent Living options are usually apartments or
patio homes for individuals above a certain age. The living units are
designed with aging adults in mind, so they are usually one-story with
wide doorways and nothing that would impede a walker or wheelchair. Some
meals in a common area may be included, or at least available, and there
are usually a variety of planned social activities. Many adults are able
to stay in Independent Living facilities for many years with the
assistance of home care agencies.
Retirement Communities are restricted to residents
over a certain age (e.g., 62), and they usually provide a lot of social
activities. Sun City, Sun Lakes and Leisure World are examples of
Retirement Communities in Maricopa County. The living units are usually
barrier-free, and they may have some of the other types of facilities
listed here on their property, but the basic Retirement Communities do
not provide any services or assistance to residents who need a little
Assisted Living is for adults who need help with
everyday tasks. They may need help with dressing, bathing, eating or
using the bathroom, but they don’t need full-time nursing care. The
residents may live in small studio apartments or a single room, with or
without a roommate, and the facilities provide meal service and social
activities similar to (and sometimes shared by) Independent Living
facilities. Some Assisted Living facilities are part of Retirement
Communities. Others are near Skilled Nursing facilities, so a person can
move easily if needs change.
Memory Care facilities are specifically licensed to
care for individuals with dementia. As with Assisted Living facilities,
they can be free-standing, or they can be part of Retirement
Communities, which would enable a resident to transition from one level
of care to another, or allow spouses to live on the same campus.
Care Homes are private residences licensed by the
State of Arizona to provide Assisted Living and/or Memory Care level of
care to a small number of residents (usually fewer than 10) in a home
setting. Care Homes are often less expensive than institutional
Continuing Care Residential Communities (CCRCs) are
communities that include Independent Living, Assisted Living, Memory
Care, and Skilled Nursing facilities on the same campus. Once someone
has paid the fee and moved into the Independent Living area, she can
progress to the other sections if and when needed for little or no
4. What does this care cost?
There is a range of costs for every type of care
that can be chosen. Home care agencies charge an hourly rate, and the
cost of Care Homes or other residential facilities can range from
approximately $3,000 to $8,000 per month or more, depending on the
amenities and level of care provided.
5. How will we pay for this?
Most families pay for Long Term Care from their
income and savings. If you purchased private Long Term Care insurance,
or it was provided by your employer, it can help offset some of the
Some public benefits may be available to help. For
example, veterans who served during wartime or their surviving spouses
may be eligible for a pension benefit, including an additional benefit
if they are homebound or require regular aid and attendance. Also, the
Arizona Long Term Care System (ALTCS) will cover the cost of long-term
care for individuals who meet strict medical and financial criteria.
6. What about Medicare?
Medicare does not cover the cost of non-acute or
“custodial care,” such as non-medical home care, independent or Assisted
Living, or even residence in a memory-care unit for people suffering
from dementia due to a stroke, Alzheimer’s or other cause.
Medicare will cover up to 100 days in a Skilled
Nursing facility if the patient had been admitted to a hospital for at
least three days within 30 days of admission to the SNF. If at least 60
days have passed since the patient was discharged from an SNF, and the
patient is admitted back to the hospital for at least three days and is
then discharged to the SNF, the “clock” starts over again. There is no
limit to the number of times Medicare will cover 100 days of skilled
nursing, provided it is preceded by at least 60 days outside an
institution, and at least three days of hospitalization.
Medicare will pay 100% of the cost of the SNF during
a period that is covered. After that, Medicare Part A covers 80% of the
cost. If the patient has a supplemental insurance policy, that policy
will cover all or part of the remaining 20%; if the patient does not
have a supplemental insurance policy, the patient is personally
responsible for that co-pay. Once Medicare will no longer cover Skilled
Nursing care, either because it is determined not to be medically
necessary or the 100 days has run out, a supplemental policy will not
cover it either. However, some supplemental policies will cover up to
one year, as long as the care meets the Medicare definition of
Medicare Part A will also cover the cost of medical
care provided at home, if it is ordered by a physician and follows a
period of hospitalization. Medicare is currently in the process of
transitioning the payment of all home care to Part B.
Medicare Part B pays for most (but not all) medical
home care if it was included in the discharge orders from the SNF or
prescribed by a physician. There is no cap on the amount or duration of
care that they will pay for, as long as a doctor continues to order it.
7. Who decides where the person should go?
Ideally, the patient will be able to express his
preference about where he wants to go and the type of care with which he
is most comfortable.
Does Everyone Need a Power of Attorney and Advance Directives?
If this is not possible due to illness, the next
best thing is for the patient to have signed advance directives when he
was competent to make decisions. Advance directives authorize someone to
act on a person’s behalf when illness prevents her from making an
informed decision or she is not able to communicate the decisions she
has made. There are several types of advance directives:
A general power of attorney appoints an agent to
make financial decisions on behalf of the incapacitated adult, such as
paying bills and managing assets.
A health care power of attorney appoints an agent to
make healthcare decisions on behalf of an incapacitated adult, such as
where she should get care, what kind of treatment is acceptable, and
when the decision should be made to withhold further treatment. In many
cases, a living will goes hand-in-hand with a health care power of
attorney. This is the document in which an individual expresses her
desires about health care decisions.
A mental health power of attorney is either a
separate document or a part of the healthcare power of attorney that is
signed separately, appointing an agent to make the decision to admit the
patient into a Level One Mental Health facility. In Arizona, a secure
memory care unit is considered such a facility. Arizona is one of only a
handful of states that requires this specific authority.
If there are no advance directives, the individual
may be able to sign a health care proxy to name someone who can make
decisions about a particular period of hospitalization or care. For
financial decisions, an individual may have given a child signature
authority on their bank account, or their assets may be held in trust
and managed by a trustee.
As Arizona is a community property state, an
individual’s spouse generally has equal authority to make decisions
regarding financial matters. In extreme cases, when no agent has been
appointed and the individual is physically or mentally incapacitated, a
guardian and/or conservator may need to be appointed by the Probate
Court to make decisions for the individual.
8. Who can help with all of these decisions?
Placement Services can help you identify a
residential facility that meets both your care needs and your budget and
can coordinate the admission process.
Geriatric Care Managers can assess the patient’s
needs, make recommendations for care providers, interface with the
patient’s doctors, and make sure that all services are coordinated.
An attorney who specializes in wills and trusts or
elder law can help with advance directives, guardianships and
conservatorships and benefits planning. Forms for health care powers of
attorney and living wills are available on the Arizona Attorney
General’s website (www.azag.gov).
As a team of legal and social services
professionals, Marsha and Tracy work with you and your family to develop
a plan of action to handle your loved one’s legal, financial, health
care, housing and long-term care needs now and in the future, including
assistance qualifying and applying for public benefits if they should
Once the plan is in place, Tracy monitors the care
and serves as the family’s advocate, in conjunction with Marsha’s
expertise with any legal challenges that may arise.
Goodman focuses her practice on Life Care Planning for seniors
and their families. She has been recognized as a Certified
Elder Law Attorney by the
National Elder Law Foundation.
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