Best Practices for Handling Referrals to Rehab & Skilled Nursing Facilities

June 26, 2013

Transitioning from a doctor’s care to a rehabilitation center or skilled-nursing facility can be fraught with anxiety for many patients. In the large majority of cases, these are older patients with chronic or debilitating illnesses or are post-surgery and are not able to care for themselves or be cared for by loved ones at home, so they are often fragile – emotionally and physically – and need to be treated with extra kindness and concern. Because of this, you need to be especially careful about referring and transferring them to a rehab or skilled-nursing facility. In fact, you should have a specific process in place for doing so.


(Read MOT’s article “Is Your Office Senior-Friendly?”)


“We like to make the transition for our rehabilitation patients and long-term care residents as seamless as possible,” says Mae Hinnant, manager of admissions and business development for Levindale Hebrew Geriatric Center and Hospital in Baltimore, Md. “We know that they and their families are already coping with stress because the decline of someone’s health impacts everyone around him or her.”


(Read MOT’s article “Eliminating Environmental Stressors”)


Having a system in place for handling referrals to rehab and skilled-nursing facilities is also important “for maintaining patient continuity of care and directing patients to the appropriate level of rehabilitation services in an efficient manner in order to maximize patient functional outcomes, minimize complications and discharge patients home sooner,” adds Justin Hong, M.D., assistant clinical professor of the division of physical medicine and rehabilitation at University of Utah Health Care in Salt Lake City.


Hinnant says her office tries to make the transition as uncomplicated as it can be, “and we rely on doctors’ offices to make sure that important information doesn’t slip through the cracks and that we have all of the paperwork we need together.”


What your rehab and skilled-nursing referral process should entail


First, you should have a written set of procedures for referring patients to rehab and nursing facilities so that the necessary information gets transferred along with the patient and the admission process isn’t held up in any way from mismanagement on your end. You may even want to include a checklist. Teach your staff to follow these procedures and use the checklist.


(Read MOT’s article “Must-Have Training for Your Staffers in 2013”)


Assemble a database of appropriate facilities in your area that includes their name, address, phone number, website and the names of contact personnel and physicians who treat at these facilities (assuming you aren’t one of them). Keep the database updated as changes arise, including facilities getting purchased and changing their name, personnel leaving or services and policies shifting. Provide patients and their families access to this database, and print them a copy if needed.


Be prepared to answer whatever questions patients and their families may have about the facilities in the area. It would help for you to have personally visited each facility beforehand. If you can’t answer their questions, refer them to the proper personnel at the facilities (and resolve to do some research yourself). Never dismiss questions as trivial or irrelevant—remember, we’re talking about where the patient will reside for possibly quite some time. Be patient, and don’t rush them through their due diligence process.


There should be an active and regular line of communication between the rehab/skilled nursing facility and your practice, says Hong. “If primary teams anticipate that their patients will need rehabilitation prior to discharge home, referrals should be started early on in order to facilitate a timely transfer to the appropriate level of rehabilitation when patients are medically cleared by their primary team.”


Once patients have chosen a facility, have a clear set of procedures for transferring paperwork to the facility. “Every place may have different requirements, but we look for the following: results from a history and physical, copies of consults, labs, diagnoses, therapy notes, medications, physician’s notes and nurses’ notes,” says Hinnant.


Include all of the above items – and any others that may be relevant – on your checklist, making sure you’re following HIPAA procedures to protect patient privacy. (Tip: your photocopier should be one that does not store images.)


(Read MOT’s article “How to Avoid the Most Common HIPAA Violations”)


Transfer information either electronically or physically using secure methods (encrypted emails and protected channels), and ask for confirmation of receipt from the facilities once received.


After the patient is admitted, even if you are not the attending physician at the facility, be sure to follow up with him/her or their family afterward to make sure the transition went smoothly. You can have a nurse or other staff member make the phone call, but you may also choose to do this yourself for the extra personal touch that can be very reassuring to people going through this type of transition. Take notes on the interaction, and check in on the patient periodically to see how they’re doing and possibly help transition them to a different facility if this one isn’t working out for them.


What to keep in mind when handling these referrals


One of the things that practices should try to avoid when referring their patients to skilled-nursing facilities is providing unrealistic expectations about being admitted, says Hinnant. “There may not always be an open bed if someone needs it immediately. Therefore, practices should encourage the person and/or the family to research long-term care centers and choose several that best suit a loved one’s needs. Then, they should call and take a tour of each place, fill out applications and get on waiting lists. All of the specific paperwork must be completed within 30 days of admission to a skilled long-term-care nursing center.”


Also keep in mind that for rehabilitation patients who are over 65 to use Medicare, they must have a three-day qualifying stay, Hinnant points out. “They also need physical therapy and occupational-therapy consultations.”


Your main focus should be on patient education and choice in a rehab or skilled-nursing facility, says Hong. “Patients and their families should be educated on the differences between acute rehabilitation and sub-acute rehabilitation (skilled-nursing facility, long-term acute care, transitional care unit) in regards to specialization of therapy programs, amount of therapy provided per week and frequency of physician follow-up. Patients should be informed about the potential advantages of each level of rehabilitation in relation to their specific diagnoses and current functional needs.”


Hong adds that he sometimes finds there are inconsistent messages being provided regarding acute rehabilitation and skilled-nursing facilities. “Skilled-nursing facilities are the same as sub-acute rehabilitation. There is a common misconception that skilled-nursing facilities do not provide rehab/therapies. I think that both skilled-nursing facilities and acute-rehabilitation facilities play important roles in our medical system and that, as a team, we need to focus on providing patients and their families with consistent and accurate information so that they can make an informed choice as to how to approach their rehabilitation needs.”

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