Who are Post-Acute Care Providers?

When the hospital discharges a loved one, the family caregiver might not be prepared. After all, the accident or fall happened suddenly, and there was no time to plan the post-acute care. Who had time to do that? The entire family rallied to keep the family member comfortable in the hospital. But now the discharge and your loved one cannot go home. They will need rehab therapy. So, now what?

You scramble for a rehab facility that provides post-acute care for recovering patients.The first question many family members ask, does my loved one qualify for Medicare?

The discharge planner tells you, “She needs help but doesn't qualify for skilled nursing care, the kind Medicare covers.”

In order for Medicare to cover skilled nursing care, your family member must meet the three-day-stay rule (and your mom's hospital stay is only two days).

The discharge planner adds, “But she does need some rehab and help. Try XYZ Assisted Living. They offer therapy on-site at all of its facilities, and they partner with a home health care company who provides physical therapy, which is what your mom needs.”

Look for Post-Acute Care Providers at nursing homes or assisted living communities. These facilities have found a way to improve occupancy by exploring care models that function as a private-pay bridge from hospital to home.

Skilled Nursing

Today, skilled nursing facilities offer long and short-term medical care. As health care reform puts emphasis on post-acute care and health care continuum, similar models occur in assisted living too. Services delivered range from intensive short term rehabilitation therapy to longer-term restorative care. The medical team includes the following health care professionals:• Attending physician• Medical specialists• Therapists• Rehabilitation therapists• Registered and licensed nurses• Case managers• Social workers• Registered dietitians• Activity directors• Nursing assistants

Types of Care Provided

• post-stroke recovery
• pulmonary care
• wound care
• hip fracture/replacement
• knee or another joint replacement
• neurological illnesses (Parkinson’s disease, etc.)
• cardiac or respiratory ailments
• tracheotomy weaning
• post-acute COPD episode
• post ventilator care
• post open heart (grafts, valves, stints)
• nutritional therapy
• dementia care
• respite care
• self-care tasks for improved mobility
• coping with the disease process
• tools to prevent further complications
• managing pain

Assisted Living

Hospitals refer lower acuity patients to assisted living as an alternative to skilled nursing care because some facilities have nurses 24/7. If patients don't qualify for skilled nursing coverage, hospitals refer patients to assisted living, even for the pre-surgery care.If the assisted living offers the protocols patients need to prepare for surgery, it just makes sense it’s a good fit for post-acute care. The private-pay program offers a 14-30 day stay. Since readmission to hospitals is due to medication mismanagement, falls, or lack of follow-up care, assisted living facilities are geared for safety. Some facilities partner with home health care and rehabilitation providers to offer services on-site. This allows the service to work with hospital discharge planners for short-term care.When transitioning from the hospital - assisted living facilities help patients prepare and fully recover for the return to their homes. So, they focus on gaining maximum independence.

Types of Care

• continence improvement
• contracture management
• fall management
• orthopedic fracture recovery
• pain management
• patient/family training and education
• nursing observation
• wound care and skin management
• physical, speech, and occupational rehab
• pharmacy services
• custom care plans to fit individual needs
• individualized meal plans• hospice/respite
• therapy pet visits• transportation

Other services

• meals prepared on site
• medications assistance
• daily housekeeping and laundry services
• furnished rooms, complete with bedding
• planned activities, social functions, and outings
• transportation to physician appointments
• assistance with arranging incidental medical and dental needs
• outpatient and in-house therapy

Post-acute care providers promote independence and return patients home as quickly as possible. Hiring or partnering with physicians, nurses and therapists help deliver the highest quality care and help patients obtain their highest level of independence. Many commit to meeting the needs of patients, families and communities.

Carol Marak is a contributor for the senior living and healthcare market.