Sub-acute care after a stroke
February 23, 2014 6:14 AM   Subscribe

The social worker at the acute-care rehab hospital where my mother is recovering from stroke suggested looking into sub-acute care centers. What should we look for?

My mother has pretty severe impairment on her left side, and needs more time to heal, but the rehab hospital (adhering to Medicare rules) discharges patients when they plateau, or show inadequate improvement from one week to the next.

How can you determine what makes a good sub-acute rehab care hospital? The social worker made a few informal suggestions of places she thinks do good work, and we will of course also ask the physical therapists if they have any ideas. But what sort of questions do you ask the staff at a prospective place? What sorts of things do you look for in the rehab rooms? has a helpful nursing home directory with ratings, but I don't see anything there specific to sub-acute rehab care. Everyone expects that my mother will be heading home after this second place, so we're really thinking about rehab rather than a lifetime stay.

She is in northern Ohio, currently staying at a Cleveland Clinic facility in Cuyahoga County, and she loves the staff and doctors there. (Ideally, the next place would be in Lake or Geauga Counties, if anyone has specific recommendations, though I know that's unlikely.)
posted by Francolin to Society & Culture (9 answers total) 6 users marked this as a favorite
She is talking about a nursing home. Many, maybe most NHs offer care for patients who are expected to stay for a few weeks; they are not limited to people who will be there indefinitely. The social worker would be the first stop for recommendations on suitable facilities. Medicare will usually pay for the first 100 days, if some of the recurring dodges have not been used.
posted by yclipse at 7:09 AM on February 23, 2014

Response by poster: Yes, this nursing home facility will also house long-term patients. I wonder, though, if there are particular things a family might look for when considering shorter-term rehab care that differ from the things you look for when planning a longer stay. The social worker made informal recommendations, and we're considering these.
posted by Francolin at 7:22 AM on February 23, 2014

You want a place that has good PT and OT programs as well as the usual concerns about a nursing home - it should smell clean, not have lots of vacant looking folks just parked in hallways. Is your mother's regular doctor a geriatrician? Their office should have some recommendations. You can also do the normal sorts of internet searches and check your state's listings looking for both abuse reporting and good reviews.

When my MIL was in rehab after hospitalizations we found that the nursing home portion of the senior living facility that she lived in had really good therapy, rather run down patient rooms compared to her usual digs in assisted living (she needed to be in the rehab for the degree of nursing care she needed at several times). The food was indifferent all around and that was the one real negative of an otherwise good place. I would suggest visiting and eating at any place you're considering. See if the staff is friendly, if the place looks and smells clean, what the PT and OT spaces look like. So much has to come from recommendations though.
posted by leslies at 7:37 AM on February 23, 2014 [1 favorite]

Something that was really useful to me as we moved my father out of rehab was reading the National Senior Citizens Law Center's publication 20 Common Nursing Home Problems—and How to Resolve Them (PDF). Specifically, check out the part about "plateauing"—it's important not to let them push your mother out before she's truly ready. You can and should push back on that.

(Sorry I don't have specific recommendations beyond that—I'll be following this thread with interest, though, because no one even mentioned the possibility of sub-acute rehab for my father, just tried to get him into a nursing home as fast as possible, and I wish I'd known that was even an option.)
posted by limeonaire at 7:37 AM on February 23, 2014 [4 favorites]

Seconding the idea that 'it's important not to let them push your mother out before she's truly ready. You can and should push back on that.' Be adamant that she get as much PT and OT as possible, and that some loose definition of 'plateauing' doesn't end up cheating her of therapy that will help her. Sub-acute care will definitely involve less PT and OT, because the assumption is that those people are no longer genuinely improving (having plateaued). Fight to get the most intervention and focused attention that you can, for as long as you can. Don't be guilted through medical nomenclature into helping them save money by agreeing to less-focused/less-proactive post-stroke treatment.
posted by thegreatfleecircus at 8:05 AM on February 23, 2014 [2 favorites]

Did you talk to the social worker about your mother's goals and whether or not sub-acute care will achieve those goals.

You should include in the goals:
- where (and with whom) she wants to live
- daily activities she would like to perform (if returning to previous activities, list them here. Include work, chores, sports, hobbies, volunteer work, church, family and friends, travel)
- obligations she has to others (eg spouse, pets, usual child care obligation to grandchildren, other)

Does the social worker have this full picture? Give her the picture and ask the social worker to go to PT and OT to see if they agree with the discharge plan to sub-acute care based on these goals. It could be that your mother has the wrong activities in OT that are not targeting activities in your home. Perhaps the stay in sub-acute care could be avoided by doing OT evaluation of mother's home and making home modifications before discharge, as well as arranging for community care.

My only experience dealing with social workers on discharge planning was in Canada, so I can't help with the Medicare angle. My situation was different, as I was a younger person looking to get discharged to community instead of to rehab. I had to ask for the social worker, talk to charge nurse and have my wishes charted, talk to OT and have OT push activities to prepare for home (including preparing an equipment list and arranging home evaluation), have PT push activities appropriate for home (stairs), and finally doing some of my own work to finalize discharge location. This is a whole bunch of work and tears in my part but I got the discharge I wanted. The point of the story though is that you need to push back on the social worker and have her work with your goals in mind, not just Medicare's. She needs to engage the whole team, and she should be able to hook you up with the discharge nurse who may know other options. Keep looking at facilities as a fallback but see if you can arrange for acute direct to community as the discharge plan and supports need to be in place / what specific milestones need to be achieved to make that happen (eg, dressing, independent toileting, independent feeding).
posted by crazycanuck at 9:06 AM on February 23, 2014

Based on the comments and experiences of older relatives, any facility that segregates (by floor or wing) the sub-acute and long-term residents is more desirable. It can be demoralizing, as well as potentially debilitating, for patients trying to recover sufficiently to return home to be housed alongside those who have little incentive for improvement.
posted by DrGail at 9:07 AM on February 23, 2014 [2 favorites]

Make sure you go on a tour before you select the place. I like to go at mealtime or just before, and I usually make a quick round of the gym/rehab room to see the therapists working withe residents before swinging by the dining room to see what the social atmosphere looks like.

Your mom will probably be spending most of her time doing PT/OT/ST so she may not care much about the recreational activities, but look for somewhere that has a good social dining program (lots of people eating in the dining room) so that she can get out of her room. I would look for double (not triple) occupancy rooms, private bathroom for sure. She's unlikely to have a private shower available but if you find a rehab that has those, even better!

If she is definitely just going for rehab and then going home, I would suggest a facility that has more short-term than long-term-care residents--she will be among peers then, and have better options for socialization at her level. As others have mentioned, even if she's only there for a relatively short time, you will need to help advocate for her and make sure she's not discharged before she's had the full benefit of the rehab services available to her. If they think she's "plateaued," talk to them and find other ways in which she is still improving. Medicare should pay for her first 100 days after hospital discharge.
posted by assenav at 4:48 PM on February 23, 2014

Response by poster: Thanks for all of your thoughtful and helpful answers. It's nice to have some concrete idea about what to look for should my mother have to go to another nursing/rehab center. I appreciate the encouragement about advocating for the best care where she currently is, too. The information in limeonaire's PDF link is also really valuable: a legal ruling last year (in Jimmo v. Sebelius) determined that failing to show improvement is not enough to remove patients from most kinds of rehabilitative care.

Thanks again.
posted by Francolin at 7:38 PM on February 23, 2014 [1 favorite]

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