Avoiding a Health Care Crisis

When our client Jean received a phone call from the case manager about her mom’s impending discharge from an acute care hospital, she found herself completely unprepared. From Jean’s perspective, her mom (who had suffered a stroke) still seemed so ill. Jean could not imagine a transition.

What Jean did not understand at the time was that her mother had made enough physical progress that she no longer met the criteria to be in an acute care hospital. At that point, there was another level of care that fell under the guidelines to be paid for by Medicare.

Fortunately, the case manager responsible for discharge planning had been down this path before with many families. She acknowledged how frightening these transitions can be and explained to Jean that a Skilled Nursing Facility(SNF) was now the most appropriate place for her mom.

Research is Critical

Jean had to act fast. She took time off from work and put her other family responsibilities on hold as she prepared for this stage of her mom’s illness. She now understood why an SNF was appropriate, but she was still faced with the decision of which SNF was best.

Jean took the list of facilities provided by the case manager and, with our guidance, developed an action plan. Included below are some of the things we recommended.

#1. Reach out to healthcare professionals.

Jean acknowledged to the case manager that this was all new to her and said the following:

“You do this all the time. You’ve given me a list but how do I know which facility is best for my mom? Tell me about your experiences with these facilities for people who have had strokes.”

Next, she asked similar questions of physicians on her mom’s care team.

Of course, the level of first-hand knowledge of specific facilities will vary from person to person. But given how many people come under their care, day to day, these professionals can often provide tremendous insightinto specific programs and experiences realized by others at various locations.

#2. Decide on the most important criteria for you and your family.

Of course, we all want a facility with excellent quality scores. With her list in hand, Jean made use of two very helpful web sites: Medicare.gov’s Nursing Home Compare site and CMS.gov’s Five-Star Quality Rating System. These helped Jean evaluate the options available.

But other criteria may matter as well. Location, for example. Jean’s dad was very involved in his wife’s care and had hardly left her side following the stroke. Proximity and ease of visitation was very important to him as well.

Additional considerations may include:

  • Quality of medical oversight. What team will provide the care and how accessible are they?
  • Experience with the condition your loved one has, such as post-stroke care.
  • Whether rehab professionals are permanent or contract employees.
  • Availability of a private room, if desired.

#3. Visit potential facilities.

Call the admissions professionals at these facilities and arrange for a tour. This will give you a direct experience with important members of the team and allow you to assess the overall feel and physical surroundings. For Jean, it was important to imagine her mom in one of the rooms and her dad driving there on his own.

Ask about admission criteria, bed availability, medical oversight, ratings, the rehab team, etc.

Also, make sure to meet with more than just the admissions professionals. When possible, ask to meet with the Director of Nursing, the Medical Director, and the Rehabilitation Director.

Time permitting, ask the facility to provide a short list of other client families you can speak with. This will give you another important window into the experiences of those who may have found themselves in a similar situation.

Finally, present your list back to the hospital case manager in order of priority. If you feel strongly about one facility over another, and bed availability timing is not aligning, try to negotiate for additional inpatient days that might allow you admission to your preferred facility.

Don’t Wait for the Last Minute

It’s important to keep in mind that once admitted to an SNF, the same cycle will repeat — the facility will begin planning immediately for discharge. Make sure that you are preparing right from the start, too, for the coming transition:

As soon as your loved one is admitted to a new facility, make yourself available in the first 24-48 hours, to be present for the initial assessments done by the physician, nurse, PT, OT and Speech Therapist. It is during those assessments that the objective and measurable goals are outlined for the first couple of weeks; that will determine when your loved one will be discharged. It is important for you to know what the goals are and how they will be measured.

Request a family meeting within 72 hours of the admission, during which the entire team should come together to discuss the plan of care, the objective and quantifiable goals, and the anticipated discharge date. Reassessments occur regularly and the date can change. But knowing from the start where you stand will help you plan effectively and discuss issues that require problem solving.

If it appears that a discharge to home, even with services, may not be possible, begin the process of investigating long-term-care facilities, using the approach described above.


I am pleased to say that things are going well for Jean’s mom and that she met her goal of transitioning home. That’s wonderful.

Still, the same result could have been achieved with less stress for everyone involved, had Jean known earlier how important it is to take steps immediately and plan for resources that may be needed.