Rehabilitation following surgery or a serious medical event is increasingly provided in skilled nursing facilities (SNFs). These patients are typically admitted for a short-term stay, in order to receive intensive rehabilitation services, followed by discharge back into the community, rather than being transferred to an extended care facility. Although the rehabilitation services may represent an opportunity to benefit from increased revenues, unique risks arise in delivering rehabilitative care to this resident population.

For SNFs accustomed to providing long-term services for elderly and often frail residents, providing short-term services focused on rehabilitation of a healthier population presents additional potential exposures, such as:
  

• Unrealistic expectations. Short-term residents and their families may have unrealistic expectations for achieving or surpassing their prior level of functioning within a short time frame.
    
• Higher acuity. Short-term residents are likely to have significantly higher acuity at the time of admission to the SNF than long-term care residents. Since these admissions may result from a recent traumatic injury, acute illness or surgical procedure, they may require more – rather than less – nursing services than long-term care residents.
    
• Overestimating the ability to function. When higher functioning residents are admitted to a SNF following trauma, illness or surgery, they may overestimate their ability to function independently and are thus at greater risk for falls that may reinjure the surgical site and/or cause a new injury.
    
• Greater propensity to initiate legal action. When higher functioning residents become seriously injured as a result of an adverse event, they and their family members may be more likely to initiate legal action against the facility than a resident who was significantly compromised prior to admission.
    

If aging services communities wish to offer services to these short-term, higher paying residents, updates and modifications to resident care practices are required in order to safely and effectively accommodate the specialized needs of this resident population. The following steps should be included in pursuing this initiative: (1) Develop policies and procedures specific to short-term-stay residents; (2) Educate and train staff on caring for short-term-stay residents; and (3) Provide a physical environment attractive to short-term-stay residents.

Policies and Procedures 
All policies and procedures should be effectively communicated to new and existing employees and easily accessible to staff members. Claim allegations frequently reflect the residents’ unmet needs for staff assistance. Therefore, policies and procedures for the short-term-stay unit should reflect:
  

• 1. expectations for performing resident rounds, including who performs resident rounds, frequency of resident rounds, and activities and services to be performed during the rounds;
       
  2. actions to be taken regarding a change in a resident’s condition, including contacting the physician/practitioner and invoking the chain of command, if the physician/practitioner does not respond; and
       
  3. implementation of physician/practitioner orders.
       

Staff Education and Training
Staff education and training should begin with a discussion of the risks associated with this resident population, such as
  

• Who is most vulnerable at this juncture in the continuum of care? 
    
• What are their increased risks and the actions implemented to decrease each risk?
    
• When should staff members contact supervisors and resident physician/practitioner, as well as when to invoke the chain of command to respond to a resident’s change in condition?
    
• Why are the residents at increased risk?
    
• Where are medications, supplies and equipment stored?
    

Next steps in education would include review of protocols specific to a short-term-stay unit. Reference materials should be readily available for staff members at their workstations. Training should include the process for and implementation of rehabilitation resident care plans. These care plans should include the special risk factors, as well as unique vulnerabilities presented by each resident. The education and training should culminate in staff understanding assistance available to ensure provision of safe resident services, incorporating expectations and accountability for resident care provided on the rehabilitation unit.  

Accommodations in a Separate Setting for Short-term-stay Residents 
Where possible, the short-term-stay unit should be located in a dedicated wing or on a separate floor, and also be designed to encourage interaction with other short-term-stay residents. Candidates selecting a SNF for rehabilitation often seek a hotel-like environment. Amenities may include conveniences the residents have in their own homes, such as large screen televisions, computers and other upscale electronics. In this environment, residents can potentially provide one another with informal support in managing decreased independence and the effort required to return home.  As this resident population has more in common with its peers than with other residents at the SNF, such interaction can become an additional resource for short-term-stay residents to pursue.  

Being able to treat and accommodate short-term-stay residents at SNFs is associated with both reward and risk. While it may represent a smart financial decision, the risks can be significant. If well-prepared, these risks can be managed proactively.

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