Cold Storage

The False Promise of Post-Acute Care

As a physician trained in both emergency medicine and internal medicine, I practice as both an ER physician and a hospitalist. In my work as a hospitalist, I was trained to think of skilled nursing facilities (SNFs) as inherently safer than discharging a patient home, believing they could provide more intensive rehabilitation to improve patients’ strength and functionality in a way that could not be achieved outside of the hospital. However, my experience as an ER doctor often showed me the opposite—patients sent to the ER from their nursing homes were often in worse shape than before they arrived.

This dichotomy was perplexing. As a hospitalist, I would discharge patients to these SNFs, trusting they would receive the care they needed. Yet, as an ER doctor, I grew increasingly frustrated with the care provided by those same facilities. It was as though I was holding two conflicting views in my head simultaneously, almost without realizing it.

The turning point came when a relative with chronic neurologic problems went to a SNF after a hospital stay for an acute illness. She had previously been cared for at home for the preceding 20 years, despite her very intense long-term care needs, and was slowly declining as she aged but was generally stable. Once she was admitted to the SNF, her condition deteriorated rapidly; she stopped speaking and eating. The premise was that she would receive intensive therapy, but we soon realized that the care she had been receiving at home was far more intensive. Upon returning home to her husband’s care, she made significant improvements and returned near to her previous baseline.

This personal experience prompted me to critically re-evaluate skilled nursing facilities and the promises we make to our patients about them.

Discharge Options

Skilled nursing facilities are designed to provide intensive medical care and rehabilitation services to patients who are not yet ready to return home after hospitalization. These facilities offer a range of services, including physical therapy, occupational therapy, and round-the-clock nursing care. On the other hand, home healthcare entails providing professional medical services and support within a patient's home, enabling them to recover in a familiar and comfortable environment.

The necessity of these options arises at the point of hospital discharge when patients are deemed not fully recovered but no longer require acute hospital care. An acute care hospital is an ideal place to receive intensive medical treatments such as intravenous medications, surgeries, or procedures. However, it is not an ideal place to recover. Hospitals cannot provide the focused and consistent physical therapy that is crucial for the rehabilitation process. Additionally, the environment in hospitals, with constant alarms, lab draws, and vital sign checks, often prevents patients from getting the restful sleep they need to heal.

Physical and occupational therapists often evaluate patients during their hospital stay, making recommendations based on their assessments of the patient's physical capabilities and potential for falls or other complications. This assessment is the primary factor in a physician's recommendations as to whether a patient should be discharged to their home or to a nursing facility.

Liability

The decision to discharge a patient to a SNF versus home healthcare is laden with liability considerations. Physicians are understandably cautious about discharging patients to their homes, fearing the repercussions if a patient falls or experiences a setback. There is an implicit belief that if a patient were to suffer a fall at a SNF, the responsibility lies with the facility rather than the physician. This belief influences many discharge decisions, leading to a preference for SNFs over home healthcare.

We rationalize that SNFs provide a safer environment, with constant supervision and medical support. However, this assumption does not always hold true. Studies such as those by Ottenbacher et al. (2014) and DeJong et al. (2009) have demonstrated that home recovery can be more beneficial for patients, offering a familiar and comfortable setting that promotes healing. Moreover, home healthcare is significantly cheaper, reducing the financial burden on patients and healthcare systems.

Unseen Risks

In practice, SNFs often function more like storage warehouses where patients continue to decline rather than recover. The structured environment of a SNF can lead to a loss of independence and a decrease in the patient's morale, which in turn affects their overall recovery. Gaugler et al. (2007) highlighted the psychological and emotional challenges patients face in institutional settings, which can hinder their rehabilitation process.

Moreover, SNFs frequently face staffing shortages and high patient-to-staff ratios, compromising the quality of care provided. Jones et al. (2018) underscored the impact of these factors on patient outcomes, suggesting that the perceived safety of SNFs may be more myth than reality. Mor et al. (2010) also pointed out the higher rates of hospital readmissions from SNFs, indicating that these facilities may not be as effective in promoting long-term recovery as commonly believed.

Home Healthcare

Considering the data and my personal observations, I argue that home healthcare, when adequately supported, is a superior alternative for many patients. Home is where the heart is, and the familiarity and comfort of one's own surroundings can significantly boost the recovery process. Patients benefit from being surrounded by loved ones, maintaining as much of their independence as possible, and engaging in their daily routines.

Furthermore, home healthcare can be tailored to meet the specific needs of each patient, providing personalized care that is often lacking in SNFs. This approach not only enhances patient satisfaction but also improves outcomes and reduces costs. The studies by Ottenbacher et al. (2014) and DeJong et al. (2009) support this perspective, highlighting the benefits of home-based recovery in terms of both patient well-being and economic efficiency.

Moving Forward

As healthcare professionals, it is imperative that we reevaluate our discharge practices and consider the evidence supporting home healthcare. While SNFs will always have a place in the continuum of care, they should not be the default option even for significantly deconditioned or disabled patients. Instead, I argue that we should try to get our patients back home if it is at all reasonable to do so.

My own relative, who is now doing well at home, exemplifies the benefits of home healthcare. Her husband, who has historically adhered to every medical recommendation from his trusted physicians, has learned from this experience. He will now refuse SNF placement for his wife whenever it is recommended (and it almost certainly will be recommended at the conclusion of every hospitalization she ever has for the rest of her life, given the nature of her neurologic condition). He will now risk being perceived as a frustrating family member, but in my personal and professional opinion, he will be right.