---

| Cory Fosco

| A daughter walks into her mother’s assisted living apartment the way she has a hundred times before. Her mother has been there more than a year, and the hard part, the daughter thought, was behind them. But there have been two falls in a month. The nurse mentioned that the mornings are getting harder.

After 34 years in long-term care, I want families to know from the beginning. Placement is not a final answer. It is a chapter. A change in care is not a failure of the placement. It is a feature of aging and serious illness.

The signs are familiar. Falls that happen more often or lead to injury. Weight loss nobody can explain. A hospitalization the person does not bounce back from. New medical needs that call for more monitoring than the setting can provide. For someone living with dementia, more wandering or new agitation.

One hard week is not a verdict. A pattern that keeps building in the same direction usually is.

Often, a hospitalization arrives before the family is ready. A social worker hands over a list of skilled nursing facilities and a discharge date a few days away. Hospitals have to move patients safely to the next appropriate setting, and beds have to open for the next person who needs care. No one is hiding the options, and everyone in the building is working against a deadline.

Federal rules apply on both sides of that list:

• The Skilled Nursing Facility Value-Based Purchasing Program began its FY 2027 year on October 1. It scores facilities on eight measures. Two concern discharge. One tracks successful discharges to the community. The other measures the percentage of skilled nursing stays in which the resident meets or exceeds an expected discharge function score. CMS withholds 2 percent of facilities’ Medicare fee-for-service Part A payments and redistributes 60 percent of that amount as incentive payments based on performance.
• On the hospital side, the discharge planning rule says patients and caregivers are active partners in planning post-hospital care. A hospital helping a patient choose a skilled nursing facility must share relevant quality and resource-use data, include a list of available participating facilities in the discharge plan, and explain the patient’s freedom to choose among them. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) hospital survey asks patients whether staff took their preferences, and those of their family or caregiver, into account when deciding what care they would need after leaving the hospital.

Neither measures whether the family understands what comes after the handoff. There is no recognized measure of family understanding in long-term care. The closest work I could find is Eric Coleman’s at the University of Colorado, whose Care Transitions Measure asked hospital patients, not families, whether they understood their care after discharge.

Original Medicare generally requires a qualifying inpatient hospital stay of at least three consecutive days for skilled nursing coverage. Time spent under observation or in the emergency room before admission does not count, even if the person stays overnight. Some Medicare Advantage plans and approved arrangements may waive the requirement, so families need to check the rules for the person’s plan and circumstances.

In 2016, the HHS Office of Inspector General recommended that CMS analyze whether outpatient time should count toward the three-night requirement, so beneficiaries receiving similar hospital care would have similar access to skilled nursing. H.R. 3954, introduced in June 2025, would count observation time. It is a proposal, not current law.

Many people are enrolled in Medicare Advantage, where skilled nursing benefits and prior authorization rules differ by plan. In a report issued in June 2026, the Office of Inspector General reviewed requests made to 19 Medicare Advantage organizations in June 2024. They denied 12 percent of skilled nursing admission requests. Enrollees or providers appealed 18 percent of the denials. Plans overturned 95 percent of those appeals in the enrollee’s favor.

In 2021, MedPAC recommended that Congress replace the skilled nursing value-based purchasing program as it was then designed with a new value incentive program. CMS has since expanded the existing program from one measure to eight.

I am a big fan of paying for successful transitions. The most practical move CMS could make would be to treat family understanding as part of the care pathway rather than an afterthought at discharge.

Cory Fosco has spent 34 years in long-term care and is the author of The Question of When. Discover a free family checklist.