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Understanding Post-Acute Care: A Guide for Caregivers and Patients

Post-acute care is a crucial part of the recovery process for patients after hospitalization, particularly for seniors. Understanding how it fits into the recovery journey and how to choose the right facility for you or your loved one can give you peace of mind as you prepare for hospital discharge.

What is post-acute care?

Post-acute care covers a range of medical and supportive care services, such as rehabilitation, palliative services, and the management of chronic illnesses and/or disabilities, provided to patients who are transitioning from an acute care setting — such as a hospital — but are not yet ready to return home. The goal is to increase a person’s ability to care for themselves and become more independent.

Your care team may recommend you or your loved one to receive post-acute care for a variety of reasons, including:

  • Short-term rehabilitative care: Patients who require short-term rehabilitative care or therapy following an illness, surgery, or injury may need help regaining their independence and returning to their daily activities.
  • Preventing unnecessary hospital readmission: Post-acute care aims to prevent unnecessary hospital readmissions by promoting the functional recovery of older adults and ensuring they receive the appropriate care and support needed after discharge.
  • Frailty: Patients who are considered fragile due to exhaustion, weakness, weight loss, limited physical activity and/or walking slowly may require post-acute care to help regain their strength and functioning.
  • Physical or mental limitations: Patients who have physical or mental limitations that make it unsafe for them to be at home alone might need post-acute care services to support their recovery and ensure supervised care.

What are the different types?

There are different types of post-acute care available to support a patient’s recovery and maximize their functioning after hospitalization. Some of the main types include:

  • Inpatient rehabilitation facilities (IRF) or inpatient rehabilitation units in hospitals, which help patients who have become weaker while in the hospital to regain strength and independence so they can safely go home or to another independent living option.
  • Long-term care hospitals (LTCH), which provide care to higher acuity patients who require a longer recovery period.
    Skilled nursing facilities, which offer specialized nursing care, rehabilitation services, and assistance with daily activities for patients recovering from illness or surgery.
  • Home health services, which provide medical and non-medical care services to patients in their homes, such as nursing care, therapy, and assistance with personal care.
  • Palliative services, which focus on providing relief from the symptoms and stress of a serious illness and can be provided alongside curative treatment.

The choice of post-acute care depends on various factors, such as the patient’s medical condition, the level of care required, and the available support system at home. The healthcare team will evaluate these factors and recommend the most appropriate type of care accordingly.

The benefits of post-acute care facilities

Post-acute care facilities play a crucial role in the recovery process and contribute to improved patient outcomes. Some benefits include:

  • Increased independence: The primary goal of post-acute care is to help patients become more self-sufficient. By providing tailored therapies and support during the recovery process, patients can regain their functional abilities and confidence in caring for themselves.
  • Access to specialized professionals: Post-acute care facilities offer patients access to skilled nurses, therapists, doctors, and other professionals who specialize in their specific needs. These professionals provide expert care and guidance to ensure patients receive the most appropriate and effective treatments during their recovery.
  • Prevention of complications: Post-acute care facilities aim to prevent further hospitalizations or life-threatening complications by closely monitoring patients and providing ongoing medical support. Through early identification and timely intervention, potential issues can be addressed, reducing the likelihood of more serious problems arising in the future.
    Tailored care plans: Post-acute care facilities often develop individualized care plans for each patient. Because they receive the most effective interventions for their unique needs, patients experience better outcomes and a smoother recovery process.
  • Integration with broader healthcare systems: Post-acute care is increasingly becoming integrated into broader healthcare systems. New business models and partnerships are emerging to enhance the coordination and delivery of care.

Choosing the right facility

When you need to find a post-acute care facility after hospital discharge, time is of the essence. Before you make your choice, consider the following factors:

  • Location: Consider the convenience of the facility’s location, as it can impact your access to necessary resources and support.
  • Services offered: Check for the specific post-acute care services you require for your recovery and functioning.
  • Quality measures: Research the quality measures related to the facility, including aspects such as clinical capabilities and outcomes.
  • Cleanliness and comfort: Evaluate the cleanliness, comfort, and attractiveness of the facility. It should feel like a home away from home, with a pleasant temperature, smell, and lighting.
  • Discharge planning and information transfer: Ensure the facility adheres to the requirements for transferring necessary medical information to ensure continuity of care.

Paying for care at a facility

There are many ways to pay for post-acute care at a skilled nursing facility. Options include:

  • Medicare: For eligible individuals, Medicare can cover a portion of the costs of skilled nursing facility care. Medicare covers the full cost for days 1-20. Starting from day 21, you will be responsible for a daily co-payment. Medicare covers the rest of the daily charges for up to 100 days.
  • Medigap insurance: To help cover costs not covered by Medicare, you can purchase supplemental Medigap insurance.
  • Medicaid: Accepted by Medicaid-certified nursing facilities, Medicaid will pay 100% of the costs of nursing home care. Coverage includes the cost of care, room, meals, and medical supplies, which are included in the daily rate.
  • HMO and managed care insurance plans: Skilled nursing facilities may accept HMOs and managed care plans. It’s important to know which plans are accepted and the services covered under your plan.
  • Savings and investments: Personal savings and investments can be used to pay for post-acute care at a skilled nursing facility.
  • Long-term care insurance: A long-term care insurance policy can help cover the costs of post-acute care services.
  • Federal and state long-term care insurance programs: Some government programs may help cover costs for eligible individuals.
  • Veterans benefits: Veterans may qualify for benefits to cover post-acute care services.

[You can read more about CareOne’s financial options here.]

Preparing for what’s next

When looking for a care facility, making an informed decision is critical. At CareOne, we invite patients’ families to tour our facilities whenever possible. You can also take advantage of live chat via the CareOne website for quick answers about our post-acute care services.

How does post-acute care fit into the elder care continuum? Read our guide to senior care options to find out.