What happens after a hospital stay if the patient hasn’t completely recovered?
When a patient no longer needs to stay in the hospital but still requires medical treatment, rehabilitation, and nursing care, post-acute care facilities help patients regain their independence or manage chronic conditions.
For some patients, post-acute care facilities help them avoid being readmitted to the hospital after being discharged. In all these cases, post-acute care is essential to restore the patient’s health, further healing, and support their wellbeing and transition to independence.
Some examples of post-acute care include:
- Rehabilitation centers
- Home health services
- Skilled nursing facilities
Understanding post-acute care
The term "post-acute care" refers to medical and supportive care provided to patients after an acute hospital stay. In direct contrast to the intensive, short-term interventions of a hospital stay, post-acute care involves continued recovery services, rehabilitation, and management of the chronic condition after the patient is discharged from the hospital. It is a major step in the broader continuum of care, ensuring that patients receive the necessary assistance to regain their abilities and reduce the risk of complications or rehospitalization.
The primary goal of post-acute care is to restore function and promote independence, while preventing costly and potentially dangerous readmissions. Patients with major surgeries, strokes, traumatic injury, or acute exacerbations of chronic conditions often require more assistance than what can be provided at the time of discharge from the hospital.
In post-acute care, specific therapies are implemented in conjunction with medical oversight to optimize recovery and enhance quality of life.
This phase of care should address not only physical healing but also provide emotional and social support for the patient, recognizing that full recovery often depends on multiple aspects of health.
What are the types of post-acute care settings?
Both facility types and models of services differ in post-acute care, each intended to meet the specific needs of patients based on their condition and recovery goals. Here are three common types of post-acute care settings.
Skilled nursing facilities (SNFs)
Skilled nursing facilities offer a higher level of medical care than traditional nursing homes. SNFs provide these kinds of services:
- 24-hour nursing services
- Assistance with activities of daily living such as bathing, dressing, and feeding
- Therapies like physical, occupational, and speech therapy
Patients being treated in SNFs are usually recovering from surgery, serious illness, or injury that requires continued nursing care and rehabilitation but does not require the intensive resources of a hospital. SNFs provide a point of transitional care for patients who continue to require significant medical input but are sufficiently stable to avoid a hospital environment.
Inpatient rehabilitation hospitals
Inpatient rehabilitation hospitals offer multidisciplinary programs designed to restore functional independence in patients requiring intensive therapy. These hospitals provide more intense rehabilitation services compared to SNFs and generally require several hours of daily therapy for patients.
Patients with the following conditions typically require stays in inpatient rehabilitation hospitals:
- Post-stroke
- Spinal cord injuries
- Brain injuries
- Major orthopedic surgery patients, such as hip or knee replacements
Care given is specialized and coordinated among physicians, therapists, nurses, and social workers, targeting rapid progress in mobility, cognition, daily living skills, and overall health.
Home health agencies and outpatient therapy
If a patient can complete their recovery at home, it sometimes proves to be a better option. Home health agencies and outpatient therapy programs provide these post-acute services. Home health agencies deploy nurses, therapists, and aides to a patient's home to provide these services:
- Medical treatment
- Wound care
- Medication management
- Rehabilitative services
The outpatient therapy centers offer continued physical, occupational, and speech therapy to patients who can travel but still require specialized support to regain or maintain their function. These settings promote a greater degree of independence and comfort for patients while they continue their recovery.
Covering the spectrum of care from facility-based to home and outpatient services, post-acute care ensures continuity and flexibility tailored to meet the diverse recovery trajectories of individuals.
Services and clinical focus areas
Services in post-acute care are varied, yet all share a common focus on restoring and maintaining patient health through clinical and supportive interventions.
Physical, occupational, and speech therapy
Therapy programs are often central to many post-acute care plans.
- Physical therapy is designed to improve strength, balance, coordination, and mobility. The patient is helped to walk again, manage pain, and avoid falls.
- Occupational therapy focuses on daily living skills, including dressing, cooking, and the use of adaptive devices, to foster independence.
- Speech therapy targets communication disorders, difficulties in swallowing, and cognitive-communication impairments, especially for those patients recovering from strokes or brain injuries.
These therapies are often modulated according to assessment findings and the patient's objectives, with progression in intensity and duration.
Medication management and wound care
Post-acute settings enable close monitoring of complex medication regimens to prevent adverse effects or interactions. Proper adherence and dosage adjustments will, therefore, be critical in managing chronic diseases or postsurgical recovery.
Wound care is equally important and applies to cases involving surgical incisions, pressure ulcers, or diabetic wounds. The skilled nursing staff is qualified for the following tasks:
- Dressing changes
- Monitoring for infection
- Using wound healing techniques
Chronic disease management
Many post-acute patients have underlying chronic diseases that include but are not limited to heart failure, diabetes, or COPD, all of which require continued monitoring and disease-specific management. This involves educating on lifestyle changes, monitoring symptoms, and coordinating with primary care regarding exacerbations and complications.
It is a holistic approach that supports healing from the acute event and prevents future hospitalizations, while also achieving long-term wellness.
The patient journey: From hospital to post-acute care
Transitioning from hospital to post-acute care involves coordinating the efforts of healthcare providers, patients, and their families to ensure a smooth and safe transition.
Coordination with discharge planners and case managers
Hospital discharge planners assess the patient's current medical status, functional abilities, and social support before discharge and recommend the most suitable place for post-acute care. They coordinate with the case manager in:
- Organizing referrals
- Scheduling therapies
- Preparing the patients and caregivers for the next phase
Effective communication among hospital teams, receiving facilities, and outpatient services is essential to prevent information gaps that can compromise the quality of care.
Insurance and authorization processes
Insurance is an important determinant of the options and access to post-acute care services. Most post-acute services require prior authorization from either insurers or Medicare/Medicaid programs, which may affect the timing and choice of facility.
Patients and their families often require assistance in navigating their insurance benefits and understanding the coverage limits. Typically, the social worker and case manager collaborate to obtain approvals and develop care plans that consider financial limitations.
This complex system has led to efforts aimed at developing better discharge planning protocols to facilitate smoother transitions and ensure improved outcomes for patients.
Quality and outcomes measurement
An important step in post-acute care is measuring the quality and effectiveness of services for patients; this, in itself, is an assurance of the best recovery support for patients. Quality can be measured in the following ways.
Readmission rates
A key performance indicator becomes the rate at which patients return to the hospital upon discharge from post-acute settings. Lower readmission rates mean:
- Successful stabilization
- Comprehensive care management
- Adequate patient education
Hospitals and post-acute facilities coordinate to reduce avoidable readmissions through targeted interventions and improved care coordination.
Functional gains
Improvements in patients’ functional abilities, such as mobility, living skills, and communication, are important markers of rehabilitation success. Functional gains reflect the extent to which post-acute programs are capable of enabling individuals to return to independent living and achieve a better quality of life.
Patient satisfaction
Surveys of patient and family satisfaction inform providers about the effectiveness and humanity of services. Feedback drives enhancements in therapy programs, nursing care, and overall patient experience.
Government quality programs
The Centers for Medicare & Medicaid Services reports quality scores and satisfaction data publicly for many post-acute care facilities. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems survey gauges patient perceptions and helps drive transparency and accountability. These measures incentivize continuous quality improvement efforts across the post-acute care landscape.
What is the importance of post-acute care?
Post-acute care is a crucial component of the healthcare system, serving as a bridge between a hospital admission and full recovery. Without it, patients might not fully recover and may not regain independence. Patients also need post-acute care to manage their chronic conditions and to avoid being hospitalized again.
Post-acute care coordinates with various professionals to facilitate the patient's restoration, including medication management, wound care, and education about next steps.
In a changing healthcare landscape that is increasingly integrated and value-based, this type of care plays an integral role in ensuring optimal long-term health outcomes and healthcare system efficiency.
Learn more about the difference between hospital and long-term care nursing here.
