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

Post-acute care is a critical part of the healing process for patients, particularly seniors, following hospitalization. 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 that patients receive the most appropriate and effective treatments during their recovery.
  • Prevention of complications: One of the primary goals of post-acute care is to prevent additional hospitalizations or major complications that could be life-threatening. By closely monitoring patients and providing ongoing medical support, post-acute care facilities can help to identify and address potential issues early, reducing the risk of more serious problems arising later on.
    Tailored care plans: Post-acute care facilities often develop individualized care plans for each patient, taking into account their unique needs and recovery goals. This customized approach ensures that patients receive the most appropriate and effective therapies and interventions, leading to better outcomes and a smoother recovery process.
  • Integration with broader healthcare systems: Post-acute care is increasingly being integrated into broader healthcare systems, with new business models and partnerships emerging to enhance the coordination and delivery of care.
Choosing the right facility

When you or your loved one need to find a post-acute care facility after hospital discharge, you don’t have a lot of time to decide. Before you make your choice, consider the following factors:

  • Location: Consider the facility’s location, as it can impact your access to necessary resources and support, as well as overall convenience.
  • Services offered: Ensure the facility offers the specific post-acute care services you require for your recovery and functioning, as well as any additional services, such as comfort care or end-of-life care if needed.
  • Quality measures: Research the quality measures related to the facility, which may include aspects, such as clinical capabilities and outcomes. This information can provide insight into the overall quality of care provided.
  • 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: Check if the facility adheres to the requirements for the transfer of necessary medical information to the receiving facility or appropriate post-acute care provider, to ensure a smooth transition and 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. Beginning on day 21, you will be responsible for a daily co-payment, while Medicare will pay the remainder of the charge per day for up to 100 days.
  • Medigap insurance: To help cover the co-payment costs that Medicare does not cover, you can purchase a supplemental policy also known as Medigap insurance.
  • Medicaid: Accepted by Medicaid-certified nursing facilities, Medicaid will pay 100% of the costs of nursing home care, including the cost of care, room, meals and medical supplies, all of 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 that are 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, including skilled nursing facility care.
  • Federal and state long-term care insurance programs: Some government programs may help cover the costs of post-acute care for eligible individuals.
  • Veterans benefits: Veterans may be eligible for benefits that can help cover the costs of post-acute care services, including skilled nursing facility care.
    [You can read more about CareOne’s financial options here.]

Preparing for what’s next

It is critical to make an informed decision on choosing the most appropriate care setting for your needs. 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 comprehensive guide to senior care options to find out.