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FAQ for Post-Acute Care in a Rehab/Skilled Nursing Center

The term post-acute care is used to describe the rehabilitation process some patients experience, usually following hospitalization for an acute illness. Many people are too weak or sick to return home immediately and in these situations, rehabilitation in a skilled nursing facility is recommended. At Juliette Fowler Communities, we are committed to providing the highest quality medical care while you are in our post-acute rehabilitation environment.

In an effort to minimize the stress and confusion that often troubles families and patients transitioning through this part of the healthcare system, we have prepared the following answers to frequently asked questions.

Why should I transfer to a rehabilitation/skilled nursing center?

Many patients who become acutely ill and require hospitalization develop generalized weakness, which makes it difficult or unsafe for them to return home immediately after hospital discharge. This weakness is the reason most people transfer from an acute-care setting in the hospital to a post-acute care setting in a rehabilitation/skilled nursing center. Occasionally patients without weakness will need continued medical care that cannot be delivered at home, so they too are treated briefly in rehabilitation/skilled nursing centers. While most patients come directly from a hospital, there are also occasions when people become weak or sick at home and transfer directly to a nursing center, rather than a hospital.

What can I get at a rehabilitation/skilled nursing center that I cannot get at home?

The primary purpose for having you transition through a rehabilitation center is to provide constant supervision and monitoring of your physical and medical needs while you regain your strength. Patients have a variety of options for in-home care, but constant supervision by trained medical personnel is generally not available outside of a hospital or rehabilitation center.

How long will I be here?

The length of your stay will be based on the progress you make with regard to your physical or medical needs. Most patients in skilled nursing stay for a period of 2-4 weeks, but there is no mandatory length of stay and we, as your healthcare providers, are eager to get you home as soon as possible.

Who decides when I can leave?

The decision as to when you leave (and where you go upon discharge) is ultimately up to you and/or your designated decision makers, but our intention is to help educate and guide you through this process. We do this through collaborative discussion between you, your therapists, your physician, your social worker, the JFC nursing staff, and your family. Patients in skilled nursing generally remain in the facility as long as there is a “skilled need.” Typically this need is physical therapy, but complicated medical issues can also apply.

Who is in charge of my care, and who should I talk to when problems arise?

The attending physician at the rehabilitation/skilled nursing facility is in charge of managing your medical needs. Any Questions you have about medications, physical symptoms, or disease management should be directed to the attending physician at the facility. Your nursing care is managed by the facility, thus any concerns or questions you have regarding day-to-day care should be directed to your nurse or the facility’s director of nursing. Physical, occupational, and speech therapy are managed by the facility’s therapy director. You will also have a dedicated social worker assigned to your care.

What is the role of my attending physician?

Patients in rehabilitation/skilled nursing facilities are assigned a physician to help oversee medical management. Physicians and their physician assistants do not own, or have any ownership interest in the rehabilitation facility. This is generally not a permanent relationship unless you choose to stay in the rehabilitation community long-term and would like to retain the physicians’ services. You are welcome to continue seeing your personal physicians while in this post-acute phase of your recovery at the rehabilitation/skilled nursing facility. The facility’s attending physician will be communicating with your personal doctor to coordinate your care.

How often do I see my attending physician?

Unlike hospitals, patients in rehabilitation/skilled nursing centers are presumed to be medically stable and no longer in need of daily physician visits. Federal guidelines mandate monthly physician visits. The healthcare system guards against abusive business practices by limiting the number of times a physician and the physician assistant may see patients in each time frame at this level of care. At Fowler, you will see our physician or physician assistants at least twice weekly, which is generally the maximum allowed by federal and insurance industry guidelines. Our physicians however, are always available for additional visits when medical issues dictate, and they are on-call 24 hours per day to handle concerns as they arise.

I arrived at the facility yesterday, so why haven't I met my doctor yet?

Due to federal and insurance industry limitations on physician visitation, it is not always possible for a physician to see you immediately after your arrival to the facility. Most physicians are able to see patients within 3-5 days of admission. At Fowler, our physicians or physician assistants strive to meet all patients within 48-72 hours of admission, though some variance occurs depending on the time and day of your arrival. Our responsibility for your care, however, begins at the time of your arrival. If concerns arise before a physician or physician assistant has seen you, please notify your nurse of the concern and it will be addressed promptly.

We hope this information is helpful in your transition to post-acute care in rehabilitation/skilled nursing. Let us know how we can help. We take great pride in assisting with your healthcare!

To learn more about post-acute care at Fowler’s rehabilitation/skilled nursing center, please call 214.827.0813

Steven Bray, MD

Author: Steven Bray, MD, Medical Director at Juliette Fowler Communities.

Dr. Bray has been caring for patients at Fowler since 2012. He received his Doctorate of Medicine at the University of Texas Southwestern in Dallas in 1995 and then completed his Internship and Residency at Vanderbilt University in 1999. He was a practicing internist at Baylor University Medical Center in Dallas for over 12 years, and served as Medical Director of that practice for 2 years.