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Difficulty: MediumDisposition and Care Setting Transitions

An 81-year-old woman is evaluated for discharge planning on post-operative day 5 following an open reduction and internal fixation of a left intertrochanteric femur fracture. Her hospitalization was complicated by a brief episode of postoperative delirium, which has now completely resolved. She is currently medically stable, alert, and oriented. Her vital signs are within normal limits, and her surgical incision is clean and intact. Prior to her fall, she lived in a single-story home with her 84-year-old husband and ambulated independently without assistive devices. The physical therapy team reports that she currently requires moderate assistance for bed-to-chair transfers and can ambulate approximately 15 feet with a front-wheeled walker. During therapy sessions, she becomes profoundly exhausted after 45 minutes and is unable to participate in further physical or occupational therapy for the remainder of the day. The patient and her husband express a strong desire for her to eventually return home. Which of the following is the most appropriate care setting transition for this patient at this time?

  1. A
    Discharge home with home health services
  2. B
    Transfer to a long-term acute care hospital
  3. Transfer to a skilled nursing facilityAnswer
  4. D
    Transfer to an inpatient rehabilitation facility
  5. E
    Discharge to a long-term custodial care facility

Answer

Transfer to a skilled nursing facility
The most appropriate disposition for this patient is a transfer to a skilled nursing facility (SNF). The patient is medically stable and no longer requires acute hospital care, but she is not safe to return home given her need for moderate assistance with transfers and the advanced age of her only caregiver. While she clearly needs rehabilitation, she cannot be sent to an inpatient rehabilitation facility (IRF) because she is unable to tolerate the minimum requirement of 3 hours of active therapy per day. An SNF provides skilled nursing care and rehabilitation services at a less intensive pace (typically 1 to 2 hours a day), which aligns perfectly with her current physical stamina and her long-term goal of eventually returning home.

Step-by-Step Solution

1
Evaluate the patient's medical stability.
The patient's acute issues (fracture repair, delirium) have resolved, and her vital signs are normal, indicating she is ready for discharge from the acute care hospital.
To confirm that acute inpatient hospitalization is no longer medically necessary.
2
Assess the patient's functional status and home support.
She requires moderate assistance for transfers and has an elderly spouse as her primary caregiver, making a direct discharge home unsafe.
To rule out disposition directly to the home environment.
3
Evaluate the patient's rehabilitation potential and physical tolerance.
She has rehab potential but becomes exhausted after 45 minutes of therapy.
To distinguish between a skilled nursing facility (SNF) and an inpatient rehabilitation facility (IRF).
4
Select the facility that matches her tolerance level.
Since she cannot meet the 3-hour daily therapy requirement for an IRF, a skilled nursing facility is the most appropriate setting for slower-paced rehabilitation.
To match facility admission criteria with patient capabilities.

Key Concept

Patients who require post-acute rehabilitation but cannot tolerate the intensive 3 hours per day of therapy required for an Inpatient Rehabilitation Facility (IRF) should be transferred to a Skilled Nursing Facility (SNF).
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Topics

Disposition and Care Setting Transitions

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