When you no longer need the amount of care provided in the hospital, the hospital will begin the process to discharge you.
Most people hope to go directly home from the hospital after surgery or being ill. But even if you and your doctor planned for you to go home, your recovery may be slower than expected. As a result, you may need to be transferred to a skilled nursing or rehabilitation facility.
Skilled nursing facilities provide care for people who are not yet able to care for themselves at home. After your stay at the facility, you should be able to return home and care for yourself.
If your surgery is planned, discuss discharge planning with your doctors and nurses in the weeks beforehand. They can advise you about whether going directly home will be good for you.
If your stay in the hospital was not planned, you or your family should discuss discharge planning with your health care provider as soon as possible during your time in the hospital. Most hospitals have staff who coordinate discharge planning.
Planning ahead helps ensure you can go to a place that provides high-quality care and is located where you would like it to be. Keep in mind:
- You should have more than one choice. If there is no bed available in the skilled facility that is your first choice, the hospital will need to transfer you to another qualified facility.
- Make sure the hospital staff knows about the places you have chosen.
Choosing the right facility for you
It is always a good idea to check out different skilled nursing facilities to which you would like to go. Visit two or three facilities and choose more than one facility at which you would be comfortable.
Some important factors in the facilities you choose will include:
- Where the facility is located
- How well it is decorated and maintained
- What the meals are like
Remember, your most important goal is to get safely back in your home. The quality of care you receive at this facility plays the biggest role in getting you home. So when looking into the facilities that are near you or those suggested to you by friends or the hospital, find out more about them. A useful online resource is Nursing Home Compare. Get answers to questions like:
- Do they take care of many people with your medical problem? For example, if you had a hip replacement or stroke, how many patients with your problem have they cared for? A good facility should be able to provide you with data that shows they give good quality care.
- Do they have a pathway, or protocol, for taking care of patients with your medical condition?
- Do they have physical therapists who work at the facility?
- Will you see the same one or two therapists most days?
- Do they provide therapy every day, including Saturday and Sunday?
- How long do the therapy sessions last?
- If your primary care doctor or surgeon does not visit the facility, will there be a doctor in charge of your care?
- Will staff take the time to train you and your family or caregivers about care you will need at the home?
SNF; SAR; Sub-acute rehab
Baltimore, MD. US Department of Health and Human Services, Centers for Medicare & Medicaid Services; September 2007: CMS publication 10153.Medicare Coverage of Skilled Nursing Facility Care.
Update Date 5/14/2013
Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Bethanne Black, and the A.D.A.M. Editorial Team.