Nursing Home Medicare Skilled Units Offer Good Experience

Medicare skilled units inside nursing homes provide post-acute care to patients/residents who need extended recovery in this day and age of increasingly shortened hospital stays. In addition, they offer fast-paced environments and excellent experience to the nurses and other staff members who work in LTC facilities. Post-acute care is swiftly becoming the wave of the future in our healthcare system. Nurses Announcements Archive Article

Updated:  

Nursing Home Medicare Skilled Units Offer Good Experience

The nursing homes of today have greatly evolved from the facilities of yesteryear. Long term care (LTC) facilities are admitting higher-acuity patients to make up for declining Medicare and Medicaid reimbursement rates. Some nurses would say that the Medicare skilled units inside modern-day nursing homes are taking the same types of patients that would have remained on medical/surgical units in acute care hospitals just a few years ago.

According to Fiegl (2012), the Centers for Medicare & Medicaid Services (CMS) requires Medicare beneficiaries to spend at least 72 hours as hospital inpatients to qualify for skilled nursing facility care, which can provide patients with therapy and other services needed to recover from injury. After the minimum 72-hour acute care hospital stay, many of these patients are discharged to Medicare skilled units of nursing homes to continue recovering in a cost-effective post-acute setting. Once these patients arrive on the Medicare skilled unit, they can expect to receive basic nursing care in addition to rehabilitation services such as physical therapy, occupational therapy, and (if indicated) speech therapy.

Nurses who work on Medicare skilled units may deal with PICC lines, central lines, Mediports, Permacaths, and peripheral IV access since a number of the residents might be receiving TPN, Procalamine, IV antibiotics every four hours, normal saline for hydration, and other intravenous fluids. These nurses also provide care for short-term residents who require post-op recovery. Much of the time these residents are only two to three days post-op when they are admitted to the nursing home after having undergone hip and knee arthroplasties, ORIFs, laminectomies, limb amputations, colectomies, kyphoplasties, CABGs, craniotomies, aneurysm repair, hysterectomies, gastric bypass, thrombectomies, and other major surgical procedures.

Some short-term residents are admitted to Medicare skilled units to recover from medical issues such as pneumonia, CVA, acute MI, cancer, COPD exacerbation, debility, closed reduction fractures, deconditioned states, failure to thrive, CHF exacerbation, status post falls, contusions, and generalized declining functional status.

The nurses who work on Medicare skilled units perform skills such as surgical staple removal, suture removal, intravenous therapy, wound care, tracheostomy care, ostomy care, management of cervical halos, appliance of braces and splints, respiratory therapy, nephrostomy tube maintenance, diabetic management, emptying of JP drains, continuous ambulatory peritoneal dialysis, continuous positive motion, indwelling urinary catheter insertion/care, enteral feedings via gastrostomy tubes, and so much more. Some nursing homes have pulmonary units that contain residents who have tracheostomies or stable ventilators.

The short-term residents on a Medicare skilled unit normally have length of stays ranging from a few weeks up to 100 days while they recover from their various issues through rehab. Once they are deemed to be reconditioned and strong enough, their attending physicians discharge them to home. Unfortunately, some residents do not regain their strength or become fully rehabilitated. These individuals sometimes become long-term residents of the nursing home.

Medicare skilled units inside nursing homes offer post-acute care to people who need extended recovery in this day and age of increasingly shortened hospital stays. In addition, they offer fast-paced environments and excellent experience to the nursing staff who work in LTC. Post-acute care is becoming the wave of the future in today's healthcare system.

2
Up Vote Up Vote ×
TheCommuter

About TheCommuter, BSN, RN

TheCommuter, BSN, RN, CRRN is a longtime physical rehabilitation nurse who has varied experiences upon which to draw for her articles. She was an LPN/LVN for more than four years prior to becoming a Registered Nurse.

102 Articles   27,612 Posts

Share this post

Great article. With the direction healthcare is heading, I think there will be far more opportunities in skilled nursing/sub-acute than there will be in acute care hospitals. Nursing school should really start having more clinicals in this type of setting.

1
Up Vote Up Vote ×
Specializes in LTC, Float Pool, Ortho, Telemetry.

I began my Nursing career 16 yrs ago in LTC. I worked as an LPN in a Nursing Home for 1.5 yrs and have always been grateful for the experience I gained from my fellow Nurses and CNA's. I also fell in love with my Geriatric residents. I was offered an opportunity to work in a local hospital and because it meant more money and better insurance for my family I took the job. I started in Float Pool and learned so many skills but eventually ended up on an Orthopedic/Med-Surg unit. I worked on this unit for 14 yrs. We used the direct patient care model and I mastered time management and many other skills. During this time I went back to school and obtained my ASN and became an RN. I remained on my unit and became a Charge Nurse, a Preceptor, and a Clinician. I also went on to obtain my BSN. During all of these years the main patient population I cared for were the elderly or the baby boomers. My favorite! Give me a 65 y/o knee replacement over a 20y/o car accident patient any day lol! Long story short, I injured my back and just could not do direct patient care anymore. I interviewed at, ironically, the same Nursing Home I had started my career in. It is a challenge each day I walk in that building but I love it! It is hard, it is tiring, management expects too much, but I love my residents. I know them well. I know when they are sick, I know when they are in pain, I can quickly assess them when they are in respiratory distress. I was afraid I would lose my skills but actually I use them each and every shift I work. My residents are like my family. Many of them have no family or friends to visit them. It is up to us to hold their hands, to give hugs, to comfort when they are ready to leave this world. Yes, there are those Nurses who may turn their noses up when I say I work in LTC but I am sure they would be glad to know that I and my skills are there if one of their family members was admitted to my facility. I am proud to be a Geriatric Nurse. Lisa RN,BSN

1
Up Vote Up Vote ×

This is indeed the direction that healthcare is headed to. Unfortunately, increased patient acuity does not result to better nurse-patient ratio which endangers the patients and the nurses' licenses. There are facilities that would deliberately cut corners and work their nurses to death (like not having enough nurse managers/admission nurses) just to get higher end Medicare patients. This puts tremendous pressure not just for the nurses but to their orderlies as well. Worse, some facilities are not equipped well enough OR frequently run out of supplies which cause undue delays in patient care.

Having almost the same level acuity in hospitals (which have a 1:6 to 1:10 nurse-patient ratio) in nursing homes which have 1:20 to 1:30 ratio is a recipe for disaster. What's worse is the fact that new grads are increasingly becoming more shut out in hospitals and some end up working in such higher acuity nursing homes with such bad nurse-patient ratio.

Several revisions in Medicare could help ease this real-world situations in higher acuity nursing homes and in turn provide better care for post-hospital patients. But then there's the current economic situation... Let's just hope for the best.

- Erick BSN, RN (based on my current experience)

1
Up Vote Up Vote ×
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

I actually agree with some of your points. Some of the less-ethical marketing directors of nursing homes that have Medicare skilled units will mislead potential patients and families by marketing the facility as some type of acute rehabilitation hospital when the truth is far different.

Acute rehab hospitals have lower nurse/patient ratios, whereas Medicare skilled units have higher ratios. When I was working on a skilled unit, angry families would tell me that the admissions manager and social worker told them that the facility was a hospital. However, they quickly found out that their loved one had been discharged to a skilled nursing facility (SNF).

Providing safe, timely care was a challenge when you have higher acuity residents who demanded your time. However, there was only one of me and about 15 to 18 of them.

Anyhow, the skills and experience that I accrued while working in Medicare skilled units were great. I now work at an acute rehab hospital with slightly lower nurse/patient ratios, but the patient population at my workplace is almost exactly the same as what I encountered at the nursing home. Both populations were post-acute, but still too sick to go home.

Post-acute care (Medicare skilled units in nursing homes, home health, private duty, outpatient clinics) is the wave of the future in our healthcare system, so new grads who cannot land the exalted hospital job would be wise to not turn their noses up at these job opportunities. After all, nursing pay + nursing experience is better than no pay + no experience.

fjellgren said:
This is indeed the direction that healthcare is headed to. Unfortunately, increased patient acuity does not result to better nurse-patient ratio which endangers the patients and the nurses' licenses. There are facilities that would deliberately cut corners and work their nurses to death (like not having enough nurse managers/admission nurses) just to get higher end Medicare patients. This puts tremendous pressure not just for the nurses but to their orderlies as well. Worse, some facilities are not equipped well enough OR frequently run out of supplies which cause undue delays in patient care.

Having almost the same level acuity in hospitals (which have a 1:6 to 1:10 nurse-patient ratio) in nursing homes which have 1:20 to 1:30 ratio is a recipe for disaster. What's worse is the fact that new grads are increasingly becoming more shut out in hospitals and some end up working in such higher acuity nursing homes with such bad nurse-patient ratio.

Several revisions in Medicare could help ease this real-world situations in higher acuity nursing homes and in turn provide better care for post-hospital patients. But then there's the current economic situation... Let's just hope for the best.

- Erick BSN, RN (based on my current experience)

1
Up Vote Up Vote ×
Specializes in Hospice / Psych / RNAC.

Opportunity my you know what. It's been that way for years now. Whose kidding who? With all this exalted BS why don't they set nurse/patient ratios that are safe? The poor RN still runs around taking care of waaay too many patients that is even near safe.

With Obamacare taking a half billion away from medicare it's only going to get worse. You can put lipstick on a pig but in the end it's still a pig.

1
Up Vote Up Vote ×
Specializes in orthopedic/trauma, Informatics, diabetes.

I am a new grad (ADN) and I work in a facility that has LTC on one end and the other is Rehab. It is on the same campus as a hospital. I really enjoy working there. In the rehab section there are 20 beds, which have not all been filled since i have been there. I still find that the pace is slower in this place. I feel comfortable with 18 patients (with 2 VERY veteran and wonderful CNAs). I feel less rushed than when I had 5 patients in med/surg for clinical. I get time to spend talking to the pts and there is an RN supervisor if I need help.

1
Up Vote Up Vote ×
Specializes in Hem/Onc/BMT.

I disagree new nurses get good experience in such places. Any experience is better than none of course, but by no means is it a "good" one. Unless you are fortunate enough to land in a facility that offers adequate staffing and smooth day-to-day operation, too many nursing homes have potential to ruin a new nurse with bad habits and disillusionment.

I once had a Medicare patient who was admitted for wound care. When I brought his meds and proceeded to tell him what they were one by one, he waved his hand and said, "Oh it's okay. I have complete faith in you nurses." I so wanted to tell him, "Sir, you're alert, you're smart. You MUST question what we bring you. You MUST demand what you need. Most importantly, you cannot assume we're doing things right all the time."

It's not that I do not trust myself or my colleagues. We are dedicated, intelligent nurses who do our best under the circumstances. But even the best nurses are prone to make mistakes or cut corners when staffing is stretched too thin or forced to work with ridiculously short supplies.

I do agree on the importance of short-term rehab services as hospitals discharge more and more patients who are still too sick to go home. In order to make it work, the corporate and administration of the nursing homes must re-think the way they do business.

1
Up Vote Up Vote ×
Specializes in Geriatrics, Home Health.
TheCommuter said:
Post-acute care (Medicare skilled units in nursing homes, home health, private duty, outpatient clinics) is the wave of the future in our healthcare system, so new grads who cannot land the exalted hospital job would be wise to not turn their noses up at these job opportunities. After all, nursing pay + nursing experience is better than no pay + no experience.

Unfortunately, at least in my area, home health and private duty don't hire new grads, and Medicare skilled units can be very very dangerous to a new grad's license. I spent 6 hellish weeks on a Medicare skilled unit, with 1 year of experience under my belt and 2-1/2 days of training. I will never risk my license like that again.

With all of the changes coming to Medicare, why not set some hard-and-fast nurse-patient ratios? It wouldn't affect facilities that don't accept Medicare, but at least there would be some kind of national staffing guidelines. If a resident is sick enough to be in a hospital, the facility needs hospital-level staffing and resources, not an off-site pharmacy and 1 doc who comes in 3 days a week.

1
Up Vote Up Vote ×

I began my nursing career as a new grad on a medicare skilled unit with over 30 patients. It was horrible. I cried every day after work, lost sleep over my job, considered quitting all the time, wrote up my resignation notice at least once a week. But I needed that job, and something in me just wouldn't quit. After struggling to become a nurse in the first place and then being an unemployed new grad for months after graduation..I was determined to acquire experience, come hell or high water.

Knowing what I know now, after only a couple years, I would not accept that patient ratio today. It is not safe. It's not good for the patients. It's not good for staff. But if you can make it, more power to you. Something just clicked one day and it got better. I acquired skills and experience. However, I also learned that to be the best nurse that I can--I cannot work like that, under those conditions, and will never again work with that many patients that are skilled if I can't help it.

Particularly when the hospital is discharging patients that are not stable, you are unequipped to care for them in the setting without doctors or supplies or support staff, you have a very high return to acute care rate, then they come back to the facility, then they go home, then they wind up in the hospital again soon after going home because they couldn't handle their care at home. And then they come back to us, unless they die :(.

If the patient is more stable healthwise, it's usually a mess anyway, because they're lied to by admissions all the time and they feel betrayed. My facility has only one or two private rooms, but EVERY SINGLE PERSON admitted says "I was told I'd have a private room!!!" Every. Single. One. Of course more of them make a fuss than others, but it's over the top blatant and purposeful deception. Or they think they're going to get therapy every day, or for multiple hours a day; or that they can be waited on hand and foot, when the staff has 10 other people to care for. It's a cycle that's terribly hard on everybody involved except for the people who are making a buck. Unless the patient has a supportive, knowledgable and capable family to advocate for them, the vast majority of the time it doesn't work out nearly like it's supposed to, and sadly a lot of people don't have that.

Or if they DO, the family is over the top anyway and treats the staff like dirt despite the fact that we can't really change how things are. The nurses get blamed for everything that happens: housekeeping didn't put paper towels in the room, nobody mopped the floor, the food tastes bad, the food is cold, I don't like the food, I had to wait too long for my food, the doctor didn't give me exactly what I wanted, I had to wait five minutes for my pain pill, I want two pain pills instead of one, and I want them NOW, I don't feel like going to therapy and they keep asking me to, I don't like my roommate, I WANT A PRIVATE ROOM, etc etc. And whose fault is it? The nurse. And unless you coo and make sympathetic noises towards their poor, poor mother for having to wait 10 minutes for a colace then you're reported for being rude.

I can name you exactly all the good families, because they are so rare. And by good, I don't mean just blindly listening to the nurses, I mean being freakin' civil and not treating us like trash that's out to cheat them and kill their parents. I don't mind questions or even justifiable anger when things go wrong or are not how they should be. But I cannot stand the whiny entitled people who expect everyone to drop everything just for them and do whatever they want, when they want it, and if you don't you're a terrible nurse. I wouldn't walk into your workplace and tell you how to manage your time and do your job. It's ok to advocate for your family member, but I am not a robot and I don't do things just by your say so. I'm a professional, and my values and integrity and responsibility is to more than just your loved one: it's to ALL of my patients. I don't believe in the concept of a VIP patient, I treat everyone exactly the same and care for them all to the best of my ability with the resources that I have. So no, I do not care that you're related to so and so or you know the doctor personally or you've been here for 10 years. If you're inconvenienced by me, sorry. I may serve you, but I am NOT your servant.

If I had a dollar for every time a family member told me they were going to call the state for XYZ stupid reason I'd be able to buy a new car right now. And they always say it with that triumphant smug look like they're pulling out a trump card that's going to make you scurry to do what they want right then. They get awfully disappointed when you don't turn a hair...The state doesn't care any more than I do about your newspaper being late or that you don't like the brand of shampoo we supply. The state doesn't care about patients, period: if they did, they'd mandate staffing ratios and impose penalties on facilities who violate them. THAT would be an actual step towards culture change, not the BS about putting frames on every piece of paper in the facility or whatever!!!

1
Up Vote Up Vote ×

I am a new nurse turned Administrator. The types of patient we are seeing are exhausting!! I agree with you! The government doesn't give a hill of beans about our patients. My residents are getting sicker and the reimbursement is getting smaller, and their demands are high. Before you say administration doesn't care about not having enough staff , I too stay awake nights worrying about my patients. LTC is regulated more than hospitals in most states, yet they get the least support . I work the floor once in a while and see how hard the staff does work. I wish I had all the answers . I hope you consider all the back door expenses of running an operation. I know being an administrator now has really opened my eyes. So many things to comply with. So much money is spent on employees , benefits, training, licensing, OSHA, FLSA and a billion other agencies . Most people don't even consider. Hospitals can bill for supplies. Skilled Medicare units get a lump sum per day to provide all the care needs- including medications and all supplies. My facility also accepts Medicaid. We believe that everyone needs care. If my marketing person claims we run the Hilton, I'd fire her in a minute! People need to understand that we are human beings caring for human beings. The public is so educated in what our jobs are, they need to educated on how to treat people who care for your loved one!

1
Up Vote Up Vote ×

See, though, Muffin139 at least you understand that we are all human, you sound like you are a good administrator or at least try to be...it just gets disheartening when you realize you work for people who seem like they don't care about the residents or direct care staff and just about saving money, and support other people like dishonest admissions. I know not all admins are like that, I just haven't had the pleasure of meeting one yet..it's a difficult job, and one I wouldn't want to do. A good administrator must be worth their weight in gold. Trying to make resources stretch is something I know I could not do all that well--but when you're quibbling over trash bags and gloves and bandaids, denying patients medications, you're cutting corners in the wrong places.

1
Up Vote Up Vote ×