The author provides a long-term care provider’s perspective on TKA patients.

While reading Dr. Juliet Ugarte Hopkin’s recent article on criteria for skilled post-acute care for total knee arthroplasty (TKA) patients, my brain went into claim defense mode. As a post-acute rehabilitation director I was tasked with ensuring our patients were meeting the Centers for Medicare & Medicaid Services (CMS) criteria for a skilled stay, and now as an appeals specialist I’m defending those very decisions.

While the article suggested that eligibility determinations about a patient’s need for a post-acute stay were driven in part by whether or not the patient had a friend or family member available to help them, when deciding the most appropriate level of care for a patient, I recommend starting with the patient themselves and then problem-solving outward. Rather than starting with “How much help does the patient have available,” start with “What does the patient need?” and then analyze accordingly.

A patient either needs medical oversight and physical support following surgery or they do not.

If a patient needs even basic support during medical recovery but does not have ready access to it, rapid deterioration and escalation of medical risk occurs. The question of the proper environment is answered by finding the place where the patient’s medical and functional presentation intersects the lowest level of safe care.

What a patient needs for safe recovery from surgery doesn’t hinge on their support structure—it hinges on their physical and medical presentation after the procedure. We then as a team identify the right environment for safe recovery. Decision-making like the type described in Dr. Hopkin’s article runs the risk of being driven not by what the patient actually needs, but by what the team thinks. It assesses need differently based on knowing whether or not someone has friends and family around. But that’s not correct—the need is based on the patient; the presence of friends of family is irrelevant. If the team constructs different discharge expectations based solely on the presence of friends and family, or places the burden of discharge planning on the patient to organize their friends and family simply because they have them, then we’re predicating the right medical setting on something that has no bearing on the patient’s actual presentation.

Perhaps the patient does have a ready, willing, and able family member or close friend available. But even then, the choice is never to automatically think, “The patient has a daughter around, so home they go.” The person assuming care must be able to provide not just physical assistance and meal prep, but possibly oversee the taking of meds, monitor the surgical site, and recognize early signs of an infection or complication. If such a person exists and the team is confident in their ability, then you have the best possible scenario. But if the friends or family of the patient are not ready, willing, and able—or the patient is reluctant to be in their care—the assessment of patient needs cannot be based on the hospital team deciding what is reasonable to expect someone other than the patient to do. What we’re really doing is not identifying a person who can help the patient get dressed; we’re identifying a person to provide post-op oversight. It takes the right kind of layperson to do that.

A patient’s reluctance to ask family or friends to support them after recovery from surgery can include everything from worrying about a financial burden (Does the daughter have to take time off of her job to care for mom? Will she lose income for that? If the patient pays for two days of a caregiver, will that mean they will then choose not to buy their medications?) to safety (Can the petite wife help her very large husband safely up from a bed or commode? Will mom be so embarrassed about her adult son trying to help her in the bathroom that she tries to do for herself and then falls?). Those limitations can preclude what seems to an outsider sitting in a hospital office like perfectly reasonable discharge solutions. In these cases, functionally there’s as little viable oversight as the patient who has no one available at all. And if we were okay sending the patient with no one to the skilled nursing facility (SNF) for post-acute care, then we can’t create an arbitrary barrier to the person who has someone receiving the same care simply because we think the someone should really do more.

Everyone in the healthcare continuum has had patients who blur the lines between medical care and hospitality, where the suggestion of a relative or friend providing even the simplest assistance when they have medical needs is rebuffed. But my experience in 25 years of SNF management is that those people are far outnumbered by people who have legitimate reservations about what could practically be provided by their circle of support. In fact, it was far more common for us to have a patient volunteering their adult child to care for them during their post-acute episode that then resulted in a panicked son or daughter explaining to us that they worked full-time and had no paid time off with their jobs. And in the SNF environment, if the patient can’t safely be at home with her existing functional limitations, and if daily nursing treatment or rehab by therapists is necessary to remediate those limitations, then CMS requirement for reasonable, necessary, and skilled services is met.  

The question of “can someone qualify for SNF care just because they don’t have a caregiver?” isn’t the right question for our TKA folks because “care” doesn’t fully summarize their needs. The better question is “Can someone recovering from surgery who doesn’t have appropriate oversight in the home qualify for SNF care?” And the answer is absolutely—even if very briefly. Determining that a patient who has no one is somehow more eligible than a patient who has an unwilling or unable someone is not part of the guidelines.


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