This is the scenario. You (or your mother) were admitted to the hospital with pneumonia. On the third day a cheery continuing care nurse comes in and says, “You don’t have a fever, and the doctors feel you can be discharged to finish your course of antibiotics, but your nurse tells me you are still too weak to go home, so we are going to send you to rehab. Here are three facilities that have a bed for tomorrow. Why don’t you discuss this with your family and tell me which one you prefer.”

This happens dozens of times a day in every community.

Several issues immediately arise. The first is that when you ask the continuing care nurse which is best, she tells you she is not allowed to make a recommendation. Another is whether this transfer is really necessary, or whether another day or two in hospital would allow you to go home instead. If a rehab stay is necessary, how do you decide on a facility with very little time to research your options?

Remember that hospitals are paid by Medicare based on the admitting diagnosis, not on how long you are hospitalized. For pneumonia, the hospital will get the same payment if you are out in two days or spend two weeks. This means that the incentive is to get you discharged ASAP. If you feel you are almost ready to go home, dig in your heels and say you want to stay another day and then go home; they won’t like it, but will usually agree.

Also, critically: Medicare will pay for a rehab stay only if you are admitted to hospital and spend three nights. “Observation” days do not count. As the patient, you have no way to tell an official admission from an observation stay: same room, same bed, same nurses most of the time. Ask!

Most hospitals will not make recommendations about facilities. Hospitals say their reluctance is due to fear about violating a government decree that hospitals may not “specify or otherwise limit” a patient’s choice of facilities. But that rule does not prohibit hospitals from sharing information about quality, and a handful of health systems, such as Partners HealthCare in Massachusetts, have created networks of preferred, higher-quality nursing homes while still giving patients all alternatives. Most hospitals simply dump the choice in the lap of the patient and family.

One easy way to get a “first pass” screen of nursing homes is to use the Medicare website. You will see a list of all Medicare-certified nursing homes and their ratings across the results of state health inspections, staffing ratios, and quality measures. These are listed by distance from the zip code given. Staffing ratios are obvious: the more nurses, aides, and therapists per resident the better. The quality measures include such things as how often residents were successfully discharged to the community setting, how often they had unplanned ED visits or readmission to hospital, how often antipsychotic medications were started and others.

This information will let you immediately eliminate the poorly-rated nursing homes. And if all the ones on the list with openings are one or two-star (out of five), I would refuse all of them. If one or more are four or five-star, you are probably safe. The next step is to have a friend or family member visit and get a gut feeling. Do not be over-impressed with the newness of a facility or the paintings on the wall. You are, hopefully, not going to be there long, nor is this a hotel. What is crucial to a good recovery is the staff. Look around. Are most of the residents restrained in chairs? Visit the PT department. Ask residents about the food and about how quickly call bells are answered. If the staff seem defensive and uncomfortable answering such questions, this is probably not the facility to choose.

Once you are at a rehab facility, the more family involvement, the better. It is human nature for the staff to pay more attention if they know concerned family and friends are around a lot. They are also the best ones to notice if things are not going well and seek remedies. Be sure to eat even if the food is not home cooking: you cannot recover without adequate nourishment. Even if you would rather rest, do your physical therapy. Remember, the more work you put in, the sooner you get out of there.

Edward Hoffer is an internal medicine physician and author of Prescription for Bankruptcy: A doctor’s perspective on America’s failing health care system and how we can fix it. He blogs at What’s wrong with health care in America?

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