SNF, Hospice

Broken Hips and Fragmented Care


We Must Do More to Help Our Most Vulnerable Seniors Recover With Dignity and Compassion

In my 30 years as a physical therapist, I have often been asked to review cases on behalf of my fellow practitioners. One recent case in particular tugged at my heartstrings because it exemplifies the damage that can be done when we fail to put patients at the center of care, and instead treat to payment incentives. This patient, whom I’ll call “Edna,” had been discharged to a skilled nursing facility (SNF) after a hip replacement to repair her fractured hip. Edna had exhausted the 100 days of skilled therapy covered under Medicare Part A. As she transitioned to hospice care on day 102, the orthopedic surgeon wanted to know what had gone wrong.

At 90 years old, Edna had fallen and broken her hip while transferring from her wheelchair to the dining chair at the assisted living facility (ALF) she resided in. At the SNF, a picture on the front of Edna’s chart showed her as the vital matriarch of her family, with two children and five grandchildren smiling around her. In conversations with her surgeon throughout her three-day hospital stay, Edna’s family conveyed their wish to return Edna to her ALF, which would necessitate rehabilitation to improve her function.

The family’s role in setting this goal was central because Edna, like so many other seniors, had serious comorbidities that complicated her treatment, including advanced dementia, Parkinson’s, depression, and a previous total hip replacement due to a post-fall fracture of her other hip. When Edna arrived at the SNF she was fully dependent on the staff for all self-care and mobility. For one hundred days she underwent intense physical, occupational, and speech therapy. When Edna couldn’t remain alert for separate physical and occupational therapy treatments, she was strapped to a standing table for co-treatments of up to an hour at a time, day after day, as weeks turned to months. As I read her file, I wondered in disbelief, ‘to what end?’

As I continued through her notes, a comment by the physician leading her care at the nursing home provided deep insight into what had kept Edna in this SNF for so long with so little progress in the span of six short words: ‘will soon be near 100 days.’ It dawned on me that her care had been serving to maximize reimbursement under the one hundred days of skilled therapy covered under her Medicare Part A benefit. When Edna’s benefit elapsed and she was discharged from skilled care to hospice, her dependence had not changed. She had fallen an additional 8 times in the facility, thankfully without further injury. The total cost of Edna’s treatment was $62,596. Her hospital stay at $9,237 and surgical fees of $1,684 were dwarfed by the cost of her stay in the facility at $49,044.

What should have been done to prevent this situation? Most directly, Edna should have been referred to hospice care when it became clear that she would not regain function. It should have been clear to her care team that her comfort, not the constraints of finance, should be the primary focus of her twilight days on our planet. Just as importantly, the Fee-for-Service system that incentivizes providers to prioritize volume of care over of the patient’s best interest must be changed. Its goal must ultimately be to control costs and engage all of the providers who touch a patient across their episode of care.

The great tragedy of this episode is not only that Edna’s treatment was medically unnecessary and costly to our taxpayers, but that it kept her from comfort and peace during the precious time she had left. Though Edna’s picture was front and center on her medical chart, it is clear that Edna was not front and center in her care plan. Her experience served as a reminder that we must find ways for healthcare teams to put the best interests of our patients at the center of better-coordinated systems of care. Edna broke her hip; unfortunately, the system that cared for her was broken too.

Tagged: SNF, Hospice