The Myth of Rehab for Hospitalized Seniors: Forty Percent Never Return Home

Most seniors and senior caregivers believe that discharge from a hospital into a skilled nursing facility (SNF) is just  another natural and obvious step on the road to rehabilitation and recovery, with the hope of heading home on the eventual horizon.  The health care industry actively and intentionally supports this belief in the  information provided to caregivers and patients at the time of discharge.  Even the name of the SNF's sells this hope; a large number of these facilities have the word “rehabilitation” in their name.  A review of a New York’s statewide directory for example, lists 622 facilities, with over half of them having “rehabilitation” in the title. The Ohio Care Planning Council lists 802 facilities, with forty percent (40%) of them having "rehabilitation" in the title. The very name of these  facilities perpetuates a mistaken belief that a hospitalized senior whose Medicare benefit has "run out," will soon return home.

Readers of this blog know, however, that adverse health outcomes inherent to institutional skilled nursing care, and adverse health outcomes endemic, but not inherent, in these facilities, often cause short term rehabilitation to become permanent perpetual skilled care. A significant number of patients entering these facilities experience adverse outcomes, and never make it back home.  A study by the Inspector General of Health and Human Services (HHS), which incidentally only considered patients institutionalized for thirty-five (35) days or less, found that approximately one-third were injured or killed by the very nursing homes that were intended to complete the care necessary to allow them to return home.  Most of these adverse outcomes were preventable.

A 2016 study published in the journal Annals of Surgery paints a bleak picture; forty-one (41%) of patients discharged to a SNF never return home. The study examined the outcomes of patients admitted to SNFs in five states, California, Florida, New York, Texas and Washington. Worse, the researchers found an elevated risk of death with institutional care:

"It is often communicated to patients and families that discharge to an SNF is a step in the process of recovery, and because clinicians have very limited evidence about the natural history of patients discharged to SNFs, patients may be given an unreasonable expectation of return to home. This study demonstrates that a significant proportion (41%) never returns to home, and the 1- and 3-year risk of death is much greater than that in the general population."

The study concluded that "[a]mong all patients discharged to SNFs, 7.8% eventually died in an SNF and overall 1-year mortality was 26.1%." 

Previous studies suggest that health outcomes on discharge to a nursing home do not differ greatly based on the rating, or performance evaluations, of the nursing homes.  In other words, selecting a highly rated facility does not greatly improve your chance of returning home.  The choice between profit and nonprofit facilities is actually more likely to impact health outcomes with for-profit institutions lagging behind the nonprofits. 
   

Families for Better Care ("FBC"), publishes a state-by-state nursing home report card. The following are the grades, rankings, and details for the states included in the study for the  year 2019:

California:  

• California was given an overall garde of "C."
• California’s nursing home ranking plunged to No. 22 overall, that’s down ten spots from its previous report card high.
• The percentage of California nursing homes with one or more deficiencies ticked nearly 3 percent points higher since the last report card, dropping the measure to a failing grade for the first time.
• California’s percentage of nursing homes with severe deficiencies increased a whopping 64 percent since our initial reports, nearly 1 in 5 nursing homes were cited for actual harm or immediate jeopardy to residents.
• While California’s direct care staffing hours remained relatively high at 2 hours and 41 minutes of care per resident daily, the percentage of facilities actually providing above average staffing levels told a very different story; the number of facilities with high levels dropped nearly 40 percent since the last report card.
• A falling percentage of verified ombudsman complaints for the third consecutive report card netted the Golden State its first “A” grade in this quality measure.
• California nursing home care ranked last in nursing home quality for the Pacific Region.

Florida:

• Florida received an overall grade of "B."
• Florida dropped seven spots in its national nursing home ranking to No. 13 overall—marking the lowest overall rank for the Sunshine State in report card history.
• Florida ranks among the best states in three critical nursing home quality indicators: direct staffing hours (No. 7), the percentage of facilities with severe deficiencies (No. 8), and the percentage of verified ombudsman complaints (No. 1).
• While Florida moderately increased direct care staffing hours offered to residents daily, the percentage of nursing homes achieving those higher staffing standards declined considerably, down more than 30 percent since the last reporting period—dropping the state to its lowest level in any report card.
• Inspectors issued one or more deficiencies to nearly every Florida nursing home.
• Fewer Florida nursing homes are scoring above average inspections than ever before.
• Nearly in 1 in 5 Florida nursing homes are on the state’s watch list for dangerous nursing home conditions.
• Florida nursing home care ranks first out of the Southeast Region’s eight states.

New York: 

• New York garnered an overall grade of "C."
• New York surged higher in overall nursing home care, up 20 spots from its dreadfully low No. 45 ranking in the past two report cards.
• New York scored “A” grades in every enforcement measure for the first time.
• Despite New York’s strong showing, the state failed two critical measures: the percentage of facilities with above average professional nursing hours and the percentage of facilities with above average direct care staffing levels, ranking No. 44 and No. 45 respectively.
• New York’s nursing home staffing hours remained woefully stagnant for the third consecutive reporting period, clocking just 2 hours and 20 minutes of direct care per resident daily.
• 4 in 5 New York nursing homes had middling to below direct care nursing staff levels.
• Despite New York achieving its best ombudsman record to date, the advocacy group still verified 3 of 4 ombudsman complaints, indicating widespread concern from residents about their overall quality of care.
• New York nursing home care ranks fourth in the Northeast Region.

Texas:

• Texas recieved a failing "F" grade. Texas is America’s worst nursing home state for the third consecutive report card.
• Texas nursing home care is miserably substandard as the state failed to score even one above average grade in any quality measure—in fact, flunking 5 of 8 statistical categories.
• Despite Texas’s abysmal showing in overall ranking (No. 51) when compared to other states, there was some good news for residents; nursing home direct care staffing hours nominally improved to 2 hours and 16 minutes of care per day, that’s four minutes more care every day since the previous reporting period.
• Although fewer than 30 percent of Texas nursing homes received an above average health inspection rating, that’s still 5 percent better than what was reported in the last report card.
• 1 in 5 Texas nursing homes was cited one or more severe deficiencies. Texas regulators cited 93 percent of the state’s nursing homes for violations of federal or state laws.
• Texas ombudsmen verified nearly every registered complaint for the third consecutive report card, indicating wide-ranging problems being reported by residents and their families about grossly inadequate quality.
• Texas nursing homes struggled to employ enough licensed nursing staff to care for residents; fewer than 10 percent of the state’s nursing homes scored an above average rating in professional nurse staffing, this ranks among the lowest nationwide—only Georgia and Louisiana ranked lower than Texas in this critical safety category.
• Texas nursing homes must do a much better job safeguarding the rights and health of those elderly and disabled adults needing nursing home care—if more money is required for reimbursement to pay for increased costs, then lawmakers must find a way to allocate these needed funds.

Washington:

• Washington continued its nursing home rankings slide, dropping back seven spots to fall to No. 34 overall, plunging the state into below average territory for the first time.
  
• Washington’s nursing home grades show that care is either good or dangerously bad; the state scored above average grades in half of the the quality measures while scoring failing grades in the remaining categories.
• Despite above average grades in every staffing measure, Washington managed to score failing grades in every regulatory and advocacy measure.
• With 65 percent of Washington nursing homes being cited a severe deficiency—the highest percentage nationally—that means more Washington nursing homes had citations for dangerous conditions than did not.
• Less than 3 percent of Washington nursing homes had a deficiency free inspection—one of the nation’s worst rates.
• Washington’s nursing home care ranks last in the Pacific Alaska Region.
• Washington received a near-failing grade of "D."

For more, consider the following:

• One-Third of Nursing Home Residents Injured or Killed In Treatment;
• Are You Really Better Off in a Nursing Home than at Home? SNF Residents with Pre-existing Healthcare Associated Infections Less Likely to be Readmitted to Hospital;
• New Controversial Sign-Off Rule Increases Burdens On Skilled Nursing Facilities- Threatens Transfer To Hospitals;
• Institutional Care: America's Most Vulnerable Seniors Raped and Sexually Abused;
• COPD Patients Discharged to a Skilled Nursing Have Two Times the Risk of Death Within Year Compared to Those Who Go Home;
• Hepatitis Infection Risk in Nursing Homes Up 50%; Infection Risk Across the Board Increases;
• Resident's Death Caused By Nursing Home Failing to Follow Advanced Directives Requesting CPR;
• Nursing Home Involvement in Patient's Death Object Lesson on Aging-in-Place Planning;
• Nursing Home Worker Faces Homicide Charges in Violent Death of Resident;
• Paramedics Often Obstructed, Provided Insufficient Information On Nursing Home Calls;
• Non-Profit Long-Term Care Safer than For-Profit;
• Habits Are Hard to Break: Nursing Homes Habitually Violate Federal Standards Year After Year;
• CDC Reports That SNF Workers Most Likely Among Health Care Workers to Forego Recommended Vaccinations;
• Don't Let Institutions Plan for You: Medicaid-Eligible Nursing Home Resident Stuck With Costs of Private-Pay Room;
• Many Skilled Care Providers Still Unaware of New Medicare Rules Permitting Chronic Condition Care;
• Ohio Ranks Poorly on Long-Term Care Services Scorecard;
• Hospice Costs Medicare Less Notwithstanding that Hospice Patients Live Longer.