A hospital visit often isn’t the end of the road for medical treatment after an illness, injury, or surgery. Many people must move on to a skilled nursing facility (SNF) for temporary additional skilled medical support and rehabilitative care. The SNF environment can be crucial, as services and support at home may not be enough to help a person recover and return to their normal level of functioning. This article guides families, showing what you can expect when entering a skilled nursing facility for rehabilitation and skilled care following hospitalization, including the initial transition and the routines within the facility.

Transferring to a skilled nursing facility for rehabilitation

The process of transferring a patient to a SNF starts early, typically with a discharge plan while the patient is still in the hospital. This discharge plan includes assessing whether the patient needs further skilled nursing support and whether a SNF is appropriate. This is also the point where the patient and their family may get involved in choosing the specific SNF that the patient transfers to.

The initial transfer

Medical transport is standard when transferring to an SNF, and Medicare may even cover the cost if it is deemed medically necessary. If they can safely do so, patients may also be able to travel with family members instead.

Handoff information

The hospital’s discharge plan includes essential details about the patient’s medical history, current health, medications, and ongoing needs. This information is shared with SNF staff early to give them time to prepare and ensure a smooth transition.

When patients arrive at the SNF, a nurse will typically review any hospital instructions and ensure the patient’s needs are met from the beginning. Immediate steps may be necessary to make the patient comfortable, especially if transport is difficult or stressful.

Initial meetings

Within the first few days of admission, multiple meetings and assessments will occur, starting with a welcome and facility orientation. A care conference will also take place, and the patient’s health status and medication history will be considered to develop a tailored rehabilitation and care plan. 

Inside the facility

Skilled nursing facilities are designed to be as homelike as possible. They include private and semiprivate rooms, often with bathrooms. Patients can bring personal items to make the rooms feel more familiar.

Patients also have plenty of freedom and shared spaces to connect with others and feel more relaxed. Such approaches help to promote independence while giving patients the support they need to recover.

What families should bring

Important things to bring include:

• Current medications and any required medical equipment.
• Health insurance cards, ID, advance directives, emergency contacts, and any other important information.
• Clothes and accessories.
• Personal care items, like a toothbrush, toothpaste, and hairbrush.
• Tools for hobbies, like knitting.
• Items for entertainment, including electronic devices like phones or tablets.
• Items to increase comfort, like the patient’s pillow from home.

Things to leave at home include:

• Perishable food.
• Large amounts of money or expensive items.
• Sharp objects like scissors and knives.
• Tobacco products or alcohol.
• Pets.

Daily and weekly routines

Routines vary depending on patients; some will need more practical support, more skilled nursing care, or longer therapy sessions. Key types of therapy include physical therapy, speech and language therapy, and occupational therapy.

Despite differences between patients and types of therapy, SNFs promote regular daily routines that give patients enough rest, free time, and social connection. Meals are typically served in a common dining area, offering an additional social connection between patients.

Although routines vary by patient and facility, a typical day could look something like this:

• The patient wakes up and is assisted with basic morning routines, like a bathroom visit and dressing.
• A nurse visits to help with medications and medical care, including wound care.
• Breakfast, with as much or as little support as needed.
• Some time to rest before tailored therapy sessions.
• Lunch, with as much or as little support as needed.
• Therapy sessions may continue after lunch if needed.
• Then there is time for dinner and some social connection.
• Assistance is provided again at bedtime to ensure the patient can rest well and that all their needs are met.

Independence is encouraged throughout the patient’s stay, and they are also taught how to continue rehabilitation once they leave the facility and return home. 

Professionals and their roles

Important professionals at SNFs include the following:

• Social workers: These professionals can help with challenges around finances and insurance while easing the concerns of family members. They can also be important in the transition back home by assisting patients in understanding their options and what to expect.
• Nursing staff: Registered nurses (RNs), certified nursing assistants (CNAs), and other nursing staff are responsible for tasks like medication management, wound care, care coordination, health monitoring, and personal care. They’re also closely involved in teaching patients how to care for themselves once they leave the facility.
• Medical staff: These doctors are the primary care providers at a SNF. They’re responsible for physical exams, medical orders, and the patient’s care plan while in the facility.
• Specialized therapists: There are also trained and specialized therapists, including physical and occupational therapists. These individuals provide specialized therapy that helps people return to their previous activity level after illness, injury, or a surgical procedure.

Other staff members may also be present, including administrative staff, patient representatives, a nutritionist, and food service workers.

How families can be involved

Families can be involved in many parts of the process, including the initial discharge from the hospital and transfer to the SNF. Families are important, as they’re a source of consistency and help ensure that staff at the SNF have all the information needed to care for the patient adequately.

A crucial approach for families is to understand the patient’s medical history, health status, and needs as best they can while the patient is in the hospital. This information will help families better advocate for the patient.

Being involved in their loved one’s SNF care also ensures that family members understand the patient’s needs as they change. This allows them to support the patient during their stay at the SNF and encourage any necessary rehabilitation exercises once the patient has returned home.

Senior care facility rules and requirements vary based on company-specific policies and state-level regulations. The content above represents common guidelines but may differ from a particular facility’s policies or requirements. To learn the regulations that apply in your state, contact your local Oasis Senior Advisor.