Table 2.

Information hospital-based clinicians commonly evaluate to help select patients for SNF

Data point	Quote	Clinician (clinical setting, years of experience)
Physical function	We also consider strongly prior level of function…insurance is…more likely to approve if they’re functioning below their baseline status.	Physical therapist (University, 4)
Social support	I just know that sometimes the alternative to go home is worse because there’s nobody at home…you’ll get family members like, ‘I can’t take care of him. I don’t know what you’re going to do with him but I can’t do anything with him.’ And that’s tough.	Nurse (University, 1)
Cognition	Patients that have maybe dementia…that’s a hard one I really struggle with, like what’s their ability to learn, what’s their ability to make progress…what are their abilities to actually learn some new skills and improve their balance so that they can go home.	Physical therapist (Safety-net, 8)
Pain	If pain isn’t controlled, then to me, they’re not ready to go. To me that’s criteria number one, I mean you’ve gotta have pain controlled, well controlled so that they can work with therapy, and obviously, if they’re going to rehab because they’re mostly there for therapy…	Physical therapist (VA, 5)
Home Environment	He’s [the patient] definitely kind of not meeting the criteria as far as for discharge home. He lives independently, he has stairs, again, has to be pretty independent obviously with him living alone, but in this case we’re recommending subacute rehab to kind of help…	Physical therapist (VA, 5)
Insurance status	I think the biggest factor I see is insurance. Does this person have resources for that beyond because…we get a lot of people that are self-pay or no benefits, and then it becomes a situation, well what can we do for them at home, and that’s kind of tough because you know that they would benefit from a skilled nursing facility.	Nurse (University, 1)
Medical readiness	I guess the decision…has more to do with, do I expect there to be a decline in status in the next 24 to 48 hours and can the place where we’re sending the patient do the things that need to be done for this patient, and if not, then they stay.	Hospitalist (University, 10)
Patient goals and motivation	A big part is gonna be, does the patient want to be there [SNF], and is the patient willing to actively participate. If the patient is in the hospital and says I’m not going to participate and then we have a couple days in the hospital where they are refusing therapy in the hospital…it’s gonna be a waste of everyone’s resources, right, to send them.	Social worker (University, 2)
Value of SNF	So if we focused on…explicitly thinking about what we can offer the patient and what a short-term stay would do for them, if we say yes, they would benefit then I think that it’s something that can really be improved upon.	Hospitalist (University, 1)