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I was going to move forward with physician documentation following the decision to admit to an inpatient rehabilitation facility (IRF), but before doing that I think that it’s prudent to explore the other post-acute care settings and their characteristics. When we say that patients cannot safely be treated in less intensive settings, the question is what is, “what is it that those other settings offer and what are their limitations”?

Post-acute care (PAC) includes rehabilitation or palliative services that beneficiaries receive after, or in some cases instead of, a stay in an acute care hospital. Depending on the intensity of care the patient requires, treatment may include a stay in a facility, ongoing outpatient therapy, or care provided at home. In general, post-acute care providers typically include: IRFs, Home Health, Hospice, Long Term Acute Care Hospitals (LTACH), and Skilled Nursing Facilities (SNFs).

Beneficiaries who are generally restricted to their homes and need skilled care (from a nurse, physical, or speech therapist) on a part-time or intermittent basis are eligible to receive certain medical services at home. Home health agency (HHA) personnel visit beneficiaries’ homes to provide services including skilled nursing care, physical, occupational, and speech therapy, medical social work, and home health aide services.

The Medicare hospice benefit covers a broad set of palliative services for beneficiaries who have a life expectancy of six months or less, as determined by their physician. Beneficiaries who elect the Medicare hospice benefit agree to forgo curative treatment for their terminal condition. For conditions unrelated to their terminal illness, Medicare continues to cover items and services outside of hospice. Typically, hospice care is provided in patients’ homes, but hospice services may also be provided in nursing facilities and other inpatient settings. Hospice providers can be freestanding entities or based in hospitals, skilled nursing facilities, or home health agencies. The hospice benefit is designed to provide pain relief, comfort, and emotional and spiritual support to patients with a terminal diagnosis. To provide this type of care, the benefit covers an array of services, such as: skilled nursing services; drugs and biologicals for pain control and symptom management; physical, occupational, and speech therapy;  counseling (dietary, spiritual, family bereavement, and other counseling services), home health aide and homemaker services; short-term inpatient care, inpatient respite care and other services necessary for the palliation and management of the terminal illness.

Patients with chronic critical illness— those who exhibit metabolic, endocrine, physiologic, and immunologic abnormalities that result in profound debilitation and often ongoing respiratory failure—frequently need hospital-level care for relatively extended periods. Nationwide, most chronically critically ill (CCI) patients are treated in acute care hospitals, but some are admitted to long-term care hospitals (LTCHs). These facilities can be freestanding or co-located with other hospitals as hospitals-withinhospitals (HWHs) or satellites. To qualify as an LTCH for Medicare payment, a facility must meet Medicare’s conditions of participation for acute care hospitals and have an average length of stay greater than 25 days for certain Medicare patients. . Under the prospective payment system (PPS), discharges are assigned to case-mix groups containing patients with similar clinical problems who are expected to require similar amounts of resources. Each case-mix group has a national relative weight reflecting the expected costliness of treatment for a patient in that category compared with that for the average LTCH patient.

Beneficiaries who need short-term skilled care (nursing or rehabilitation services) on an inpatient basis following a hospital stay of at least three days are eligible to receive covered services in skilled nursing facilities (SNFs). Medicare covers up to 100 days of SNF care per spell of illness.1 Beginning on day 21 of a SNF stay, a beneficiary is responsible for a daily copayment. In 2019, the copayment is $170.50. In 2018, Medicare estimates program spending was $29 billion for SNF care. Skilled nursing facilities can be hospital-based units or freestanding facilities. Beginning on October 1, 2019, daily payments to SNFs are determined by summing payment rates for six components of care—nursing, physical therapy, occupational therapy, speech– language pathology services, nontherapy ancillary services and supplies, and non–case mix (room and board services).

The differences in post-acute care settings is striking. The characteristics of a patient who is most appropriately treated by a home care agency, hospice or long-term care hospital is quite apparent. The debate around IRF admissions typically arises from the question of skilled nursing with subacute rehabilitation services versus IRF level care with intensive services. Skilled nursing facilities (SNFs) serve as licensed healthcare residences for individuals who require a higher level of medical care than can be provided in an assisted living facility. An inpatient rehab facility offers acute care for those who need a higher level of rehabilitation following traumatic injuries and surgeries such as amputations. Skilled nursing facilities, on the other hand, offer subacute rehabilitation, which are similar but less intensive than the therapies provided at an IRF. In a skilled nursing facility, patients receive one or more therapies for an average of one to two hours per day. The therapies are not considered intensive. In an IRF, patients receive a minimum of three hours per day, five days a week, of intensive physical, occupational, and speech therapy, in addition to medical management and specialized nursing care, coordinated by a team approach.