Medicare Skilled Nursing and Rehab Care

After a Medicare recipient has had a qualifying stay of at least three days in a hospital, Medicare will pay for a maximum of 100 days of nursing facility care.  Medicare calls the 100 day interval “skilled care”, to be distinguished from acute care in the hospital. Hillsboro House is the Medicare skilled care provider in the Contoocook Valley towns from Peterborough and Concord to Hopkinton, Henniker, Warner and Bradford.

At Hillsboro House, Medicare post hospital care is often devoted to recuperation and rehabilitation, with the facility providing nursing care, physical and occupational therapy, medication, and whatever other services the individual may need related to his or her hospitalization. The goal is a simple one: to make the transition from the hospital as comfortable and effective as possible and to restore the resident to maximum function.

The Medicare skilled care interval gives us at Hillsboro House the opportunity both to meet the needs of post hospital patients and to send those patients home fully rehabilitated and recuperated. At Hillsboro House, we take our success in achieving these goals seriously.  At other skilled nursing facilities in New Hampshire, the odds of rehab care being but short by an unanticipated re-hospitalization are about 20 percent.  The same trend is seen nationally.  In contrast, our Medicare re-hospitalization rate is very close to zero – between 2009 and 2012 our rate was less than three and half percent.  The consistency of these outcomes is a result of the thoroughness of our approach:

• Medication reconciliation.  An acknowledged and widespread risk among Medicare patients is the inefficient and incomplete monitoring and evaluation of the medication regimen.  In fact, dosage and scheduling errors associated with just two medications account for nearly twenty percent of emergency admissions of elderly patients.  Hillsboro House has an experienced staff of nurses and pharmacists and doctors who rigorously review all prescribed medications for effectiveness, adequacy and safety.
• Coordination of care.  As a skilled care provider, we take seriously the task of restoring our skilled nursing residents to their previous level of function.  But we also recognize that the skilled nursing interval is productively used as an opportunity to prevent future hospital admissions.  We often find that residents admitted for skilled care come with an array of primary, specialist and sub-specialist providers who are rarely coordinated in their efforts.  Hillsboro House has developed a comprehensive care management approach, and our sustained relationships with primary and specialty care providers allows us to develop a holistic and responsive post-discharge plan of care.
• Rehabilitation services.   For the majority of our skilled nursing residents, the focus of their stay is rehabilitation.  Whether following a planned surgery or an emergency hospital admission, Hillsboro House offers physical, occupational and speech therapy services  to support a swift return to home.
• Complex nursing and advanced clinical care. By virtue of serving a population with diverse health care needs, Hillsboro House has developed unique competencies in the management of clinically complex conditions.  These areas include diabetic care management, wound care, restorative nursing and post-surgical care.  Properly approached, many of these specialties not only improve quality of life but also often eliminate the need for acute management in the future.
• Discharge planning and ongoing support.  At Hillsboro House, our relationship with our skilled nursing residents rarely ends at discharge.  It is important to us that the transition home be not only safe but also sustainable.  Our discharge planning, therefore, is comprehensive and involves the scheduling of follow-up appointments, evaluations of the home environment, the ordering of appropriate medications, supplies and equipment and the coordination of supportive services and ongoing therapies in the home.  We also often find that the relationships and familiarity developed during a skilled nursing stay position us as a reliable ongoing resource; even after their return home, our former residents often contact us with questions, concerns and requests.