Will really wanted to go home.  He had a serious complications from diabetes that had resulted in poor blood flow to his feet and legs and now he had two toes amputated.  The foot was healing but it was slow going.   We all thought he needed dressing changes, IV antibiotics and close supervision for the next month. Will agreed but he also thought he needed the comfort of his own home.

Arranging transfer to a Skilled Nursing Facility would be the easiest way to achieve a “Safe Discharge Plan”.  Will and his family would not have it.  Will rallied his wife and daughter to help with dressing changes and Will learned how to care for his PICC Line and safely connect his antibiotics. He also redoubled his efforts to follow his diet and manage his insulin to keep his glucose levels under control.  A few months later I saw him in the hallway on his way to clinic.  He was justly proud that the foot had healed.

Skilled Nursing Facilities fill an important role in our healthcare system. With complex care needs and fragmented family and social support not everyone is as fortunate as Will and many need and benefit from care in a SNF.

Rachel Werner and colleagues recently published In JAMA Internal Medicine their article “Patient Outcomes After Hospital Discharge to Home with Home Health Care vs to a Skilled Nursing Facility” The results are interesting,

• No difference in mortality or functional status.
• More readmissions to hospital in 30 days from home
• Medicare cost were significantly less at home

Home care is a safe option, when consistent with the goals of patients and families, but they need help, maybe more than Home Health is currently able to provide.  I am concerned about unintended consequences, recently hospital metrics have included readmissions in the first 30 days with penalties for when this occurs.  If health care cost and systems are fragmented, like Home Health, SNF and Acute Care, it will be difficult to align care plans that are consistent with patient and family goals of care, patient safety and lower cost.

Rachel M. Werner, MD, PhD1,2; Norma B. Coe, PhD3; Mingyu Qi, MS1 Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility; et al  Jama Internal Medicine Published online March 11, 2019. doi:10.1001/jamainternmed.2018.7998