Core Faculty and Associate Program Director JPS Hospital Fort Worth, Texas
Introduction: This case involves a 71-year-old patient with a complex medical history, including pulmonary Mycobacterium abscessus infection requiring high-cost, specialized antibiotic therapy. Although medically cleared for discharge to a skilled nursing facility (SNF), she remained hospitalized due to barriers related to inhaled amikacin administration, nebulizer disinfection protocols, and high medication costs, which SNFs usually cover. This case illustrates the challenges SNFs face in accommodating patients with unique, high-cost treatments. As complex therapies become more common, facilities must adapt to meet these needs. Addressing these barriers is essential to avoid prolonged hospitalizations, reduce costs, and improve continuity of care. This case highlights the importance of staff training, access to medication assistance programs, and partnerships with specialized facilities to enhance patient outcomes and timely care transitions.
Case Description : A 71-year-old female with hypertension, CAD, moderate aortic stenosis, chronic DVT (on Eliquis), depression, hyperlipidemia, and osteoporosis was referred from a SNF to the hospital for thrombocytopenia evaluation after completing a four-week course of triple IV antibiotics for a pulmonary Mycobacterium abscessus infection. Thrombocytopenia improved with steroids and discontinuation of Eliquis and antibiotics. Infectious Disease was consulted, and a follow-up CT showed worsening infection. The patient was started on inhaled amikacin, IV tigecycline, and azithromycin and was cleared for discharge back to the SNF to continue treatment. Despite medical clearance, the SNF declined her readmission, citing challenges with nebulizer administration for inhaled amikacin. Additional barriers included the need for prior authorization and financial assistance for the medication, which was eventually approved. She remains hospitalized, as multiple facilities declined her placement, and the family is now exploring home health care as an interim solution.
Discussion: Barriers to nursing home acceptance and timely discharge include unstable medical conditions, high-cost treatments, limited family support, insurance issues, and complex psychosocial needs. In this patient’s case, discharge was delayed due to the need for inhaled amikacin, nebulizer disinfection, and high medication costs. Most SNFs must cover these expenses under a consolidated billing model, complicating placement for patients requiring high-cost treatments like inhaled antibiotics. Addressing these barriers involves educating SNF staff to handle specialized medications, enrolling eligible patients in financial assistance programs, leveraging family support networks, and building partnerships with facilities equipped for complex cases to improve patient transitions and resource allocation.
