What it is
Where skilled nursing fits, and where it ends
A skilled nursing facility (people also say nursing home, rehab or SNF) is a licensed medical setting with nurses around the clock, physical and occupational therapy, and a doctor overseeing care. Most people arrive from a hospital for a short rehab stay after a fall, a surgery or an illness, and Medicare pays for part of that stay when the rules are met. A smaller number stay long term because they need nursing care every day.
The hard moment comes near the end of the rehab stay. The therapy goals are met or the covered days run out, the discharge planner says Friday, and the family realises that going home is not safe even with help. That is the call we get most often, and it is the one we are built for: finding an assisted living community, a memory care community or a small board and care home that can take your parent at the care level they now need, and arranging it in days, not weeks.
Our founder Anita Varelas ran licensed communities before founding Neighborly, and the team is a member of UCSF’s Preferred Provider Network and a Stanford Health Care community partner. Hospital and rehab social workers across the Bay Area send families to us for exactly this step.
Skilled nursing is the right place when
- Recovering from surgery, a stroke, a fall or a hospital stay and needs daily therapy
- Needs a nurse every day: IV medications, wound care, a feeding tube, complex monitoring
- Medically unstable and not yet safe in a residential setting
- Long-term care needs that only a nursing facility is licensed to provide
Time to plan the next step when
- Rehab is ending and going home alone is not safeAssisted living
- The main need is supervision and memory support, not nursingMemory care
- Needs a lot of hands-on help in a small, quiet setting at a lower costBoard and care
Free, no obligation
Tell us what is going on
Tell us a little about your situation and a local advisor will call or email you back, usually the same business day.
Prefer to talk? Call 866-744-1417, answered until 6 pm. Send the form any time and we reply outside those hours too. Our help is free to your family.
The next 48 hours
What to do when the discharge date lands
Families get a day or two of notice. This is the order that works, and we do most of it with you.
- Call us the same day866-744-1417, answered until 6 pm. Tell us the facility, the discharge date and what the care team is saying about needs.
- Ask the discharge planner two thingsWhat level of care they recommend, and for the facesheet and recent notes. We work directly with the social worker from there.
- We call communities that have a bed nowOur advisor checks who can take the care level this week, at what rate, and whether they can assess at the facility.
- The physician reportCommunities need a physician’s report (Form 602) before move-in. We help get it started with the facility doctor so it is not the thing that delays everything.
- Tour or assessYou tour the short list, or the community’s nurse assesses your parent at the facility. We come with you either way.
- Move-in and afterWe coordinate transport, equipment and the first days, and we stay involved after the move.
How we help
How we help from rehab to the right place
- Tell us what is happeningWhere your parent is, the discharge date, what the therapists and nurses say they need, and the budget. We can talk the same day.
- We find who can take them this weekNot a directory, a short list: communities and care homes with an open spot at the right care level, confirmed by phone before you see it.
- Assess, tour, decideMany communities assess at the facility. We coordinate that, come to tours, and help you weigh the options honestly.
- Move with everything handledPhysician report, transport, equipment, the first week. The facility gets the discharge it needs and your parent lands somewhere safe.
How we choose
How we choose the places we send you to
Before a family sees a list, our advisor calls around. Communities are asked what they have open right now, at what price and for what level of care, so the short list only holds places that can actually take your parent this week.
We share a brief overview of the situation only with the communities that fit, and we ask them to hold off on calling you until a tour or assessment is set. Your phone number is not passed around.
An advisor goes on the tours with you, helps with the physician report and the paperwork, and stays involved through move-in day.
Check a license yourself
Skilled nursing facilities are licensed and inspected by the California Department of Public Health, and the records are public. You can look up any facility, its inspections and its complaint history on the state’s Cal Health Find site. Assisted living communities and care homes are on the separate Care Facility Search. Ask us if a record is hard to read.
Four local advisors, one number. Johnell, Ashley, Tanvi and Kayevon cover the nine Bay Area counties.
Reviews
What families say
Swipe for more
Tanvi was great! She not only helped us find great assisted living options, but also helped us with the logistics of the move. She was awesome in finding both PT and transport resources we needed and saved the day for us.
It is a pleasure to write a very positive review of Tanvi Gangakhedkar’s dedication and energy to assist in transitioning my wife from skilled nursing to an assisted living facility. We looked at several facilities that she had researched and made the decision for a fairly new facility that is part of a larger network of assisted living facilities. Tanvi was sensitive and thorough in helping me ask the right questions and checking out the options for my wife’s care. I would certainly be glad to recommend her to anyone seeking help in finding an appropriate home for oneself or a family member or friend.
Neighborly helped me to find the right facility for my dad’s needs. I toured multiple facilities both assisted and memory care sides accompanied by Kayevon. She listened to our needs and wants, she helped me to ask the proper questions and ultimately find the facility that I felt the most comfortable with which had the services and care for a smooth transition for my dad. The search for a facility to meet your loved ones needs can be very overwhelming but from the start I knew that Neighborly cared about helping my dad and I to find the best fit for him Thank you Neighborly
Questions
Questions families ask
Can the hospital or rehab send my mom home if she cannot care for herself?
They can discharge her once she is medically stable, and they will, with a home health referral. Whether home is safe is a different question, and it is yours and ours to answer. If it is not, tell the discharge planner that, ask for a short extension if one is possible, and call us the same day so we can find a place that can take her.
Can my dad go straight from rehab to assisted living?
Yes, and it is the most common move we arrange. The community needs a physician’s report, a recent assessment and sometimes a TB test; most can assess your dad at the rehab facility and admit within days when a bed is open.
How fast can you help?
We can talk the same day you call and usually have a confirmed short list within a day or two. Move-ins from rehab often happen within the week, depending on the care level and what is open. Phones are answered until 6 pm and the form is read outside those hours too.
Does Medicare pay for skilled nursing?
Medicare Part A covers a short rehab stay in a skilled nursing facility after a qualifying hospital stay, with a daily copay after the first weeks and a limit on covered days per benefit period. It does not pay for assisted living, memory care or board and care homes, which are paid privately, with long-term care insurance, veterans benefits or, in some counties, the Medi-Cal Assisted Living Waiver. Check the current figures on the Medicare website or ask us.
What is the difference between skilled nursing and assisted living?
Skilled nursing is a medical setting with nurses around the clock and daily therapy, for people who need that level of care. Assisted living is a residential setting with help for daily tasks, meals and medication management, for people who are stable but cannot live alone safely. Most people leave skilled nursing for assisted living, memory care or a care home once rehab is done.
Do you place people into nursing homes?
Our work is the step after skilled nursing: finding the assisted living community, memory care community or board and care home that fits once rehab ends or when a nursing level of care is no longer needed. If your parent needs long-term nursing care, we will say so and point you to the right resources.
Is your help free?
Yes. Our help is free to your family, from the first call through move-in.
Something else on your mind? Call 866-744-1417, answered until 6 pm.
Next
Keep reading
Free, local help
Discharge date coming? Call today, not Friday
The form takes two minutes and the phone is faster. A local advisor replies the same business day in most cases, and the help is free to your family.