WHAT TO LOOK FOR WHEN COMPARING REHABILITATION FACILITIES

HERE IS WHAT TO LOOK FOR WHEN COMPARING REHABILITATION FACILITIES & SKILLED NURSING FACILITIES

When individuals first become eligible for Medicare most of them are focused on what their coverage will cost.  Some people want to feel like they got a "Great Deal" as if they were buying a new car. Others actually put in the time to compare and ask important questions, such as I know I want good coverage now, but what happens if something unexpected happens, what does your coverage look like when that unforeseen event hits you or your family member?

As a broker, I have seen so many things happen straight up out of the blue.  Like a Cancer diagnosis within a week of their Medicare Supplement Policy being in force, or; a Heart attack 9 days after they opted for a Medicare Advantage plan because the agent at the Insurance company never mentioned any other options, and now they may never qualify for a Medicare Supplement policy again.  Things like these are true, they happen every day, yet the majority of Medicare Beneficiaries fail to imagine what their coverage will give them when they really need it. And, what your options are for Care and Rehabilitation in a Skilled Nursing Facility (SNF) aka a Rehabilitation Center.

If you have Original Medicare, also referred to as Traditional Medicare, you are in great shape, however, if you are covered under Medicare Part C and have a Medicare Advantage plan, you are at a distinct disadvantage right off the bat.  This link will give you access to how Skilled Nursing Facilities work with Medicare https://www.medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf

People typically use the words “Skilled Nursing", “Assisted Living” and “Nursing Home” interchangeably, but they’re actually all different terms.

A nursing home is a term used to describe the physical building where residents receive assisted living or skilled nursing care.

Assisted living is for seniors who don’t need around-the-clock nursing care but who could use help with activities of daily living (ADL). ADL's include assistance with eating, medication reminders, bathing, dressing, and getting out of bed.

Skilled nursing care refers to a patient’s need for care or treatment that can only be performed by licensed nurses. This type of care is usually offered in Hospitals, Assisted Living Communities, Nursing Homes, and other certified locations. Skilled Nursing is mostly regulated by the U.S. Department of Health and the Centers for Medicare & Medicaid Services (CMS). To be certified by CMS, skilled nursing communities must meet strict criteria and are subject to periodic inspections to ensure quality standards are being met. And, typically there are two types of Skilled Nursing Facilities, Acute Care Facilities and Care Facilities. Acute Care Facilities will focus on more Rehabilitation (Up to 3 hours Per Day) and for only 1-2 weeks.  After that, the majority of patients will go to a "regular" Care Facility until they are deemed ready to return home or, recommended to a different type of Facility.

WHAT TO LOOK FOR WHEN COMPARING REHABILITATION FACILITIES

If you or a loved one has had a stroke, surgery, or extensive treatment for kidney, heart, or respiratory conditions, they may still require rehabilitation at a skilled nursing community, or a Rehabilitation Facility, following their release from the hospital. Medicare will pay for skilled nursing services if a physician prescribes physical and occupational therapy, medications, medical equipment and supplies, and social services, to help your loved one meet their health goals. However, to qualify, you must go to a Medicare-certified skilled nursing community.

After an illness, surgery, or hospitalization, a rehab care team will create a personalized plan for the most optimal outcome. Most typically, this involves rebuilding your strength, learning to properly walk, how to operate and use Durable Medical equipment safely, re-learning how to step up and step down after Knee and Hip Surgery, etc.

Help to adapt to social and physical environments through specialized therapies for getting dressed, memory training, and coordination exercises.

The most common Occupational Therapy tasks centered around the Five Activities of Daily Living (ADL). Activities of Daily Living (ADL's): Activities of daily living are activities related to personal care.  They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.  If a sample person has difficulty performing an activity by himself/herself and without special equipment or does not 

perform the activity at all because of health problems, the person is deemed to have a limitation in that activity.  The limitation may be temporary or chronic at the time of the survey.  Sample persons who are administered a community interview answer health status and functioning questions themselves, unless they are unable to do so.  A proxy, such as a nurse, always answers questions about the sample person’s health status and functioning for long-term care facility interviews. 

Addresses communication issues and swallowing dysfunction. Speech and language pathologists design a treatment plan to help with language ability, provide alternate communication strategies, and give appropriate diet recommendations.

Skilled nursing communities can offer a wide range of services and medical care: physical therapy, occupational therapy, speech-language pathology, wound care, intravenous (IV) therapy, injections, and monitoring of vital signs and medical equipment.

Skilled nursing staff includes:

•  Registered Nurses
•  Licensed Practical Nurses
•  The most common Occupational Therapy will be centered around the Five Activities of Daily Living (ADL). Activities of Daily Living (ADL's): Activities of daily living are activities related to personal care.  They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.  If a sample person has difficulty performing an activity by himself/herself and without special equipment or does not perform the activity at all because of health problems, the person is deemed to have a limitation in that activity.  The limitation may be temporary or chronic at the time of the survey.  Sample persons who are administered a community interview answer health status and functioning questions themselves, unless they are unable to do so.  A proxy, such as a nurse, always answers questions about the sample person’s health status and functioning for long-term care facility interviews. 
•  Audiologists
•  Medical Directors

They also must have a transfer agreement with a hospital in case a resident requires emergency care.

As you evaluate all the possible care options, here are some helpful tips to get you started and important questions to ask before you decide.

Getting started:

•  Reach out to people you trust to be unbiased – consultants, friends, family, or a physician – for their candid advice and recommendations.
•  Once you have a list of care options, the State of New Jersey Report Card for Health Facilities has been replaced by the CMS-Five Star Quality Rating System. To compare your options, visit the Nursing Home Compare webpage at Medicare.gov
• You can also check a community’s online reviews, but because personal reviews can be very objective, it’s important to weigh them with other information you’ve already collected.
•  Once you’ve narrowed down your list, start scheduling visits to your top communities. As you’re doing this, consider other important details, such as how they answer the phone, the time it takes for them to return messages, and their helpfulness.

Even if you know the differences among the types of care available, it can be hard to know which skilled nursing community is best for you or your loved one. To help seniors, their families, and caregivers compare different skilled nursing communities more easily, CMS created a Five-Star Quality Rating System that gives each community a rating between 1 and 5 Stars. A 5-star rating signifies “much above average quality” care. A 1-star rating represents “much below average quality.”

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1. What are your impressions of the place?
2. Is it warm and comfortable?
3. Does the facility look and smell clean?
4. Are the public restrooms and common areas cleaned and organized?
5. What activities are there for the patients?
6. Does the staff smile and greet residents by name?
7. Do the residents seem well cared for and happy?
8. Could you imagine your loved one living here?
9. Do they have Laundry Facilities or will you need to collect and bring back clean clothes for your loved one?

1. What’s their schedule for a typical day?
2. Try the food. How is it?
3. What’s the dining arrangement? Do residents eat in a dining room or in their rooms? Is it cafeteria-style or sit-down?
4. What’s the visitation policy? Are there set hours, or are visiting hours open?
5. What security safeguards are in place?
6. How much notice is given before discharge?
7. What’s the staff-to-resident ratio?
8. What forms of insurance does the facility accept?

Recovery after a Stroke, Knee replacement, and Hip Replacement are some of the most common reasons people go to a Skilled Nursing Facility to continue their rehabilitation.  Most often, these facilities are a bridge to your healing and recuperation so, so you can safely return home.  For others, it is a step where your needs can be evaluated to see how much care you may actually need.  For many, the answer could be transferring to an Assisted Living Facility or a Nursing Home.

Skilled Nursing Facilities are staffed by Caregivers, Administrative Staff, Doctors, Registered Nurses, Nurse practitioners, Licensed Physical Therapists, Occupational Therapists, and Speech-Language Pathologists.  As you all know, the trend at Hospitals for the last 10 years is to get you in and out as soon as possible.  Most often you are recommended for additional care and rehabilitation because you are deemed as not fully healed and not ready to return home on your own, or even with a family member/spouse.

CMS (Center For Medicare and Medicaid Services) is responsible for approving facilities to be designated as accepted facilities to continue care and rehabilitation post-surgery or after a hospital stay.  If you have chosen Original Medicare and have a Medicare Supplement Plan G, Plan F, or Plan N you are in the best possible situation.  You have coverage for up to 100  Days, completely paid for by Medicare.  You will have plenty of time to recover, and regain your strength and your mobility, at any Skilled Nursing Facility you choose, anywhere in the country, as long as there is a bed available.  

There are Good Facilities and GREAT Facilities to choose from.  However, the majority of Excellent Skilled Nursing Facilities and Rehabilitation Centers give preference to those with Original/Traditional Medicare instead of Medicare Advantage. Is that legal? Absolutely it is.  It is up to each individual facility to determine what insurance they accept.  And, the majority of the higher-rated facilities choose not to accept Medicare Advantage plans because they do not want the hassle of the insurance companies constantly badgering them to lower their rates. And, most of them have worked hard to be the best, and they are not going to sacrifice their reputation and the care they offer to their patients just to appease a For-Profit Insurance Company.

So if you or a loved one chose Medicare Advantage over Original Medicare, the only way you can go to another Facility is to pay for it out of pocket.  That cost can range from $170 - $220 per day.  So a 3-week stay would cost you around $4,000.

Rehabilitation, Cancer Treatments, and Skilled Nursing Care are some of the most glaring weaknesses of every Medicare Advantage plan, and these are also the topics one asks about and some agents are not completely honest or forthright about while they boast the virtues of Medicare Part C and Medicare Advantage plans.  These are also not the topics that are ever mentioned in the seemingly endless Medicare Advantage Television Commercials we see throughout the year. 

There are no laws or protections to say how many Skilled Nursing Facilities have to be in a Medicare Advantage Plans Network.  But, if you do not go to an SNF in your plan's network, you will most likely have to pay for that out of your own pocket.  Is that fair, no, not in my opinion.  Is that legal? Yes, it is.  What happens if there are Skilled Nursing Facilities in the network of your plan, but they do not have any beds/rooms available?  Well, simply put, you are SOL. You can look at other facilities but will normally have to pay for the care yourself, and some facilities can require you to pay upfront if you do not have Original Medicare.

I am not faulting anyone who does their research and decides that receiving their Medicare Benefits from Medicare Part C (Medicare Advantage) makes the most sense for themselves.  However, I doubt that they were ever told about the details of their plan's coverage limitations concerning Skilled Nursing Facilities, Rehabilitation Care, and Physical Therapy.  These are the areas that Medicare Advantage plans lack the most.  No one ever wants to think about Physical Therapy, but did you know that most MA/MAPD plans only cover 10 PT (Physical Therapy) visits?  The rest you have to pay for out of your own pocket.  Conversely, Medicare has no Cap on the number of therapy sessions you can have.  They will continuously re-evaluate you and as long as your Doctor and the Therapist determine that additional treatments are necessary, they will authorize it.

Establish a rapport with the Therapists and Case Manager.  Ask them if it is necessary to make arrangements to improve the safety and maneuverability of your loved one once they return home.  This can involve picking up all area rugs and loose carpets, installing Grab Bars and Railings, Removing Doors, and Enlarging Doorways in older homes to allow safe entry using a Wheelchair, Scooter, or Walker. You might consider adding a Shower Chair, Handheld Shower Head, and Safety Strips to the Tub and or Shower, of course, it just depends on the individual and what their Care Team suggests. 

It has been my professional and personal experience that Medicare will not pay for Grab Bars being installed or any modifications to the home to make it ADA-compliant.  But, if your Friend or relative has a Long Term Care Policy (LTC), it is worth reaching out to the company to see if they will cover these changes if it is suggested and in-writing from their Doctor of Licensed Therapists. Many companies will, some will not, but it is certainly worth making a phone call.

One thing I have done in the past is to take a video on my Smartphone of my relative's house.  From entering the Front Door and From the Garage.  Notating and Patios, Step-Ups, and Step-Downs in the home.  Showing the Floors, Open Space, etc. This is a huge benefit to the Patient and the Therapists as they will often see things that they know they should adjust for and can work into their therapy regimens.

Medicare will typically pay for a "Standard Walker" and a Wheelchair when a patient leaves the facility, but there are a few other items you should discuss with the Therapy team:

1. Grabbers/Reachers 

2. Long Handled Shoehorns and/or Step In Shoes

3. Plenty Of Grabber Socks

4. Dressing Aides such as a "Sock Sleeve"

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I hope you found this article interesting and eye-opening,  Hopefully, you will not have to experience this yourself, but if you do; I know you will be better prepared.  The hardest part of determining what the best and most comprehensive insurance is; is not when it is a beautiful day full of sunshine, or the fact that you are in excellent health and you can't remember the last time you were in a hospital as a patient.  The most important and sadly, oftentimes the most overlooked aspect of discussing Healthcare options and Healthcare coverage, is asking hard questions to make sure you are prepared and that you are solidly protected from the unknown and the unpredictable.

And, whenever you visit a friend or family member who is recuperating in an SNF, I hope you recall this article. At Braden Medicare, we have conversations like this every day with our clients and prospective clients alike.  Most often it is about being prepared and things we all need to be aware of as we age. And, there are times when we are asked for advice, what is a good facility, etc. If you have any questions or comments, please feel free to reach out to us, my email is mike@bradenmedicare.com and you can reach us 24/7 at https://www.bradenmedicare.com