Post-acute care (PAC) is transitional medical care a patient receives following a hospital stay, also known as acute care. Patients require this intermediate support after being stabilized from a serious illness, surgery, or injury but are not yet well enough to recover fully at home. The goal of a post-acute facility is to bridge the gap between high-intensity hospital treatment and the patient’s return to their prior living situation or a lower level of care. This care focuses on rehabilitation and recovery to help the patient regain strength, mobility, and independence.
Defining Post-Acute Care
Post-acute care provides medical services and therapy to patients who have completed the initial phase of treatment in an acute care hospital. Acute care focuses on stabilizing the patient and treating immediate, severe conditions, such as emergency surgery or managing an infection. Once medically stable, patients transition to a post-acute setting for the recovery and rehabilitation phase. The primary function of PAC is to prevent hospital readmission by providing continued skilled care that cannot be safely managed at home.
The typical patient requiring PAC has experienced a significant medical event, such as a severe stroke, a major orthopedic procedure like a joint replacement, or a serious injury. They need a structured environment where they can receive ongoing medical monitoring, specialized treatments, and physical, occupational, or speech therapy. The care is provided under the supervision of medical professionals, aiming to restore the patient’s functional status and overall quality of life.
Key Types of Post-Acute Facilities
Post-acute services are delivered across several distinct facility types, each offering a different intensity of care to match the patient’s specific needs. The three primary settings are Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, and Long-Term Acute Care Hospitals. Choosing the correct setting depends on the patient’s medical complexity and their ability to tolerate rigorous therapy.
Skilled Nursing Facilities (SNF)
Skilled Nursing Facilities provide 24-hour skilled nursing care and daily rehabilitation services for patients who are not medically complex enough for a hospital setting. Patients in an SNF are typically recovering from conditions like deconditioning, infections, or joint replacements. The therapy regimen is less intensive than other options, often totaling one to three hours of therapy per day, adjusted to the patient’s tolerance and physician orders. The focus is on medical stabilization, managing wounds or intravenous medications, and helping patients regain independence with daily activities like dressing and bathing.
Inpatient Rehabilitation Facilities (IRF)
Inpatient Rehabilitation Facilities are designed for patients who can tolerate and benefit from intensive, comprehensive rehabilitation services. Patients admitted to an IRF often have severe conditions such as a spinal cord injury, traumatic brain injury, or a debilitating stroke. The regulatory requirement is that patients must participate in a minimum of three hours of therapy per day, at least five days a week. This intensive schedule includes physical, occupational, and speech-language therapy, all overseen by a physician specializing in physical medicine and rehabilitation (physiatrist).
Long-Term Acute Care Hospitals (LTAC)
Long-Term Acute Care Hospitals treat medically fragile patients who require extended hospital-level care, usually with an average stay of 25 days or more. These patients are stable enough to leave the main acute hospital but still need continuous, specialized medical interventions. Care examples include ventilator weaning, complex wound management, or prolonged intravenous antibiotic therapy. LTACs maintain in-house physicians who provide daily oversight and close monitoring due to the high medical complexity of the patient population.
The Transition Process
The transition from an acute hospital to a post-acute facility is managed by a multidisciplinary team, primarily led by case managers and discharge planners. Discharge planning starts early, often upon the patient’s admission, to ensure a smooth and safe transfer. The case manager assesses the patient’s medical needs, functional status, and home environment to determine the most appropriate setting.
The selection of a specific PAC facility is based on medical necessity, rehabilitation potential, and the intensity of skilled services required. For instance, a patient needing intense, multi-disciplinary therapy must meet the criteria for an IRF, while a patient requiring skilled nursing for wound care will be directed to an SNF. This assessment ensures the receiving facility is equipped and trained to manage the patient’s specific complex needs. Effective communication between the hospital and the PAC provider is essential, involving the transfer of comprehensive medical information, including medication lists and advance directives.
Coverage and Payment Structures
Financial coverage for post-acute care is primarily governed by Medicare Part A, the hospital insurance program for eligible beneficiaries. Medicare Part A covers services in both Inpatient Rehabilitation Facilities and Skilled Nursing Facilities, provided the care is medically necessary. For an SNF stay to be covered, a patient must first have a qualifying hospital stay of at least three consecutive inpatient days.
Medicare Part A covers the first 20 days in a Skilled Nursing Facility after the patient meets their deductible. For days 21 through 100 of the benefit period, a daily co-payment is required from the patient, with Medicare covering the remaining amount. After day 100, the patient is responsible for the full cost of the SNF stay. Private insurance plans and Medicaid may also cover PAC services, but their rules and limitations vary widely.