Approximately 25% to 40% of hospitalized adults are discharged to receive postacute care either at home through home health or in skilled nursing facilities, inpatient rehabilitation facilities, or long-term acute care hospitals.
This Narrative Review considers postacute care settings to assist hospital-based clinicians in effectively collaborating with patients, caregivers, and interdisciplinary care teams to facilitate transitions to high-quality postacute care.
Clinicians often care for patients who cannot return to their previous level of support in the community due to new functional impairments or complex posthospital care needs. After hospital discharge, these patients may require postacute care (PAC)—broadly defined as medical and rehabilitative services intended to help individuals recuperate and rehabilitate. PAC can be provided at home through home health (HH) or in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term acute care hospitals (LTACHs). A key criterion for PAC eligibility is the need for skilled nursing and/or rehabilitative services as determined by the treating physician.1-3 Payers require that these health services be reasonable and necessary for the treatment of a specific illness or injury, and that given their complexity (eg, wound care, intravenous infusion), they be provided only by a health professional. Yet, clinicians often play a passive role in PAC planning; many report a lack of knowledge around PAC capabilities, quality, and constraints.4-6
The epidemiology of PAC in the US is best understood for Traditional Medicare (or fee-for-service). Among hospitalized Medicare beneficiaries, approximately 40% were discharged to PAC in 2023: 18% to HH, 17% to SNF, 5% to IRFs, and 1% to LTACHs,7 accounting for approximately $60 billion of Medicare spending annually.7 Up to three-quarters of regional differences in Medicare spending are attributable to PAC, suggesting that discharge decisions are often driven by local practice norms rather than patient need. This underscores the need to improve and standardize PAC best practices.8,9
Hospital-based physicians, nurse practitioners, and physician assistants play an important role in PAC discharge planning due to their in-depth understanding of a patient’s complex medical needs. A better understanding of the qualifications and services provided can help clinicians engage in a more helpful role in the PAC discharge planning process. This Narrative Review provides an overview of PAC settings with the goal of helping clinicians collaborate most effectively with patients, caregivers, and interdisciplinary care teams to promote transition to high-quality PAC. We present a general summary of the most common types of PAC, followed by a comparison of the supporting evidence for each PAC setting. Descriptions of elements of PAC are based on the benefits covered by Traditional Medicare, which generally inform other payers’ coverage policies. Lastly, we review best practices for clinicians to actively discuss PAC options with patients, helping to orchestrate transitions of care to PAC for eligible individuals.
