Navigating the Post-Acute Care (PAC) maze can be an overwhelming mystery, especially when verbally presented with the options and no map. We put together this map of the complex discharge pathways to provide a sense of the complexity.
To clarify and simplify these routes, we've distilled the information into individual sections, each accompanied by a diagram and a detailed explanation. This approach will help you understand each option more thoroughly, equipping you to knowledgably participate discharge decision making considering your specific needs and preferences. Here are the top five PAC discharge destination paths we will cover:
Placement in Long-term Care Hospital
Entering an Inpatient Rehabilitation Center
Admission to a Skilled Nursing Facility
Going Home under the supervision of a Home Health Agency
Enrolling in Palliative or Hospice Care
PAC Discharge Path #1 – Placement in a Long-term Care Hospital
If you were admitted to an Acute Care Hospital with a serious, medically complex condition that may have required critical or intensive care unit (ICU) treatment, you may be placed in a Long-Term Care Hospital. These facilities provide a continuum of care that extends beyond the typical 5.5-day hospital stay to 25 days or more. LTCHs are equipped to deliver the same levels of medical and therapeutic services found in hospitals such as prolonged mechanical ventilation, complex wound and resistant infection cure, post-surgical complication management, and multiple acute or unstable illnesses treatments. While in a Long-Term Care Hospital you may receive respiratory therapy, treatment for head trauma, and comprehensive pain management aimed at stabilizing and improving your physical and cognitive function. Note, a LTCH may be the first stop in a hospital discharge plan before your medical team considers other post-acute and long-term care options or a return home.
As diagramed in PAC Discharge Path #1 – Long-Term Care Hospital, after placement in a LTCH, you might be transferred to a Skilled Nursing Facility for continued nursing and rehabilitation support or move directly into an Assisted Living location or a Nursing Home, depending on your recovery progress. If a personal residence is your desired location, you could ultimately be discharged with Home Health Agency services. At that point, you may also want to consider engaging Home Care services to assist with specific ADLs and IADLS.
PAC Discharge Path #2 – Entering an Inpatient Rehabilitation Center
Should you need a more concentrated and structured rehabilitation regimen as the next step in your recovery, you may enter an Inpatient Rehabilitation Center (IRC). These facilities are designed for those who require intensive rehabilitation to recover from conditions such as stroke, surgery, acute illnesses, and infections. The goal of an IRC is to allow you regain as much function as possible through extensive physical therapy, antibiotic treatment, and other intensive medical interventions.
To be transferred to an IRC, your medical team will evaluate both your willingness and ability to engage in intensive therapy. This involves over three hours of therapy daily, five days a week, with a focus on making substantial progress. Your medical history will be reviewed, and you will be interviewed to determine if you have the physical and cognitive ability to benefit from intensive therapy. Additionally, the team will assess your willingness to actively participate in your recovery.
For example, the first two times my father went to the hospital, he was accepted into a Rehabilitation Center and made substantial improvements that allowed him to return home and live independently. However, as he entered his 90s and his overall physical capabilities declined, the rehab hospital no longer accepted him. Despite his history of active participation, he was no longer able to make significant progress in improving his mobility. Instead, he went to a Skilled Nursing Facility (SNF), which made us reconsider whether his Independent Living community could provide the necessary monitoring and support for him to live safely. In contrast, my mother had scheduled back surgery and often declined working with rehabilitation therapists. Despite being a nurse and aware of post-surgical requirements, she did not demonstrate a willingness to participate in extensive therapy, making her an unsuitable candidate for a Rehab Center.
If you or your loved one can undergo intensive therapy, a Rehabilitation Center could be your next step. Here, you will engage in multiple therapy sessions with short breaks in between for several hours each day. Upon showing sufficient progress, you may either return to your personal residence with support from a Home Health Agency or transition to a more permanent community location such as an Assisted Living facility or a Nursing Home, as illustrated in PAC Discharge Path #2 – Inpatient Rehabilitation.
Rehabilitation Centers serve as a bridge between hospital and home, focusing on restoring your capabilities. Stays are generally shorter than those in Long-Term Care Hospitals but longer than typical hospital stays. In advocating for the IRF path it is crucial to be realistic about your willingness and ability to participate in a rigorous therapy regimen and your potential to make substantial progress in improving physical and cognitive function.
PAC Discharge Path #3 – Admission to a Skilled Nursing Facility
Moving to a Skilled Nursing Facility (SNF) for continued medical attention and one to two hours of therapy per day is suitable for those who need less intensive rehabilitation. You may be a candidate for a SNF if your hospitalization was for multiple chronic conditions—such as congestive heart failure, chronic obstructive pulmonary disease, or diabetes requiring monitoring, wound care, or if you need support with mobility and managing daily activities, curing an infection, or experienced a neurological illness. These facilities often support longer stays, typically ranging from 24 to 60 days, depending on your condition and recovery goals. Therapy primarily aims to enhance your ability to perform ADLs and IADLs, although returning to the level of function prior to hospitalization might not always be achievable.
SNFs are staffed with nursing assistants supervised by registered nurses or licensed practical nurses, alongside various therapists. Physician visits tend to occur one to three times a week, ensuring regular medical oversight. Services in SNFs include wound management, IV therapy, injections, comprehensive monitoring of vital signs, and training to use medical equipment.
Admission to a SNF may be particularly beneficial if some of the treatments required for your recovery demand skilled nursing expertise that someone at home does not have and may not be comfortable providing. It may also be a good fit if 24-hour monitoring is required. Unlike home health care, which is provided for a few hours a day, SNFs offer round-the-clock attention, reducing the burden on family and friends. Spending some time in an SNF can be beneficial for resolving specific medical issues and regaining strength and mobility before returning home.
Skilled Nursing Facility Medicare coverage extends to a maximum of 100 days per illness episode under Medicare, following a qualifying three-day inpatient hospital stay. The first 20 days are fully covered without any co-payment, so even a brief SNF stay is an affordable option. From the 21st to the 100th day, a daily coinsurance applies.
As shown in PAC Discharge Path #3 – Skilled Nursing Facility diagram, following a hospital discharge to a Skilled Nursing Facility, you may either return home with Home Health Agency support or move to Assisted Living or a Nursing Home based on your needs and recovery.
PAC Discharge Path #4 – Going Home Under Home Health Agency Supervision
Returning to your personal residence under the supervision of a Home Health Agency (HHA) to recover is often the preferred hospital discharge path. This setup allows for continued nursing and therapeutic support, supplemented by limited home care services. A comparison of what home health versus home care services entail is presented here.
The types of services provided by HHAs include wound care, ostomy management, catheters, nasogastric or feeding tubes, tracheostomy care, medication management, improving gait or balance, infusions, treatment for complications of multiple chronic conditions, and post-acute rehabilitation therapy—physical, occupational, and speech.
Both Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) can cover eligible Home Health Agency services if you meet these specific criteria:
Be Considered "homebound". Leaving home must be a major effort due to illness or injury. For example, you may require aid like a cane, wheelchair, walker, or another person's assistance, or your condition may be such that leaving home is not recommended.
Need medically necessary services. You must require skilled nursing services for wounds, patient and caregiver education, injections, intravenous or nutrition therapy, and monitoring of serious illness. This can include a combination of physical, occupational, and speech-language pathology therapies, as well as medical social services to address social and emotional concerns. One or more Home Health Aides may assist with daily activities such as walking, bathing, and dressing. Additional services can include injectable osteoporosis drugs for women, durable medical equipment, medical supplies for home use, and disposable negative pressure wound therapy devices.
Have an approved care plan. Your doctor or another qualified provider must confirm your need for these services during a face-to-face visit and then issue medical orders. Services must be provided by a Medicare-certified Home Health Agency to be covered.
Require part-time or intermittent services. You should only need skilled nursing and home health aide services for up to eight hours per day, not exceeding 28 hours per week. In certain cases, your doctor may approve up to 35 hours per week for a limited period if medically necessary.
Once this episode concludes, you may opt to maintain or extend Home Care services to assist with daily activities. An illustration of PAC Discharge Path #4 – Home Health Agency is diagrammed below.
Home Health Agency admission can be a very rejuvenating and affordable option to receive medical care, rehabilitation, and support in the comfort of your own home. Knowing this option is available can provide comfort and reassurance. Especially if you are a caregiver for your loved one, Home Health Agency services provide valuable assistance and education to allow you or your loved one recover in a familiar and comfortable environment.
PAC Discharge Path #5 – Enrolling in Palliative or Hospice Care
Enrolling in Palliative or Hospice Care may be recommended to give you comfort and support as you approach end of life and where recovery is no longer the likely outcome due to serious or terminal illness. For more information on palliative and hospice services and benefits, refer to this GeriScope post: How and When Do You Choose Between Palliative and Hospice Care
If you are dealing with a serious or terminal illness, you may receive palliative or hospice care services in your residence or at an inpatient setting within a hospital or nursing home, focusing on comfort and quality of life. The PAC Discharge Path #5 – Palliative and Hospice Care is shown below.
Each of the PAC discharge pathways is tailored to your situation and based on a thorough assessment of your medical condition, living situation, and your ability to engage in necessary rehabilitation. This breakdown is designed to help you ask informed questions and make empowered decisions regarding your or your loved one's post-hospital care.
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