Rehabilitation Options after Your Acute Care Hospital Stay

A person has many options for their rehabilitation following a hospital stay from an illness, injury or surgery. There are many variables that can come into play which are discussed below. The most common considerations when making this decision include, but are not limited to, the following: 

• your diagnosis; 
• home environment; 
• functional level; 
• help at home to assist you with tasks;
• your ability to tolerate high intensity rehab;
• your goals;
• how long you were in the hospital;
• what intensity of rehab or skilled nursing services you need;
• whether you require nursing care in addition to rehabilitation services;
• insurance; and 
• availability of beds at local facilities. 

All of these factors play a role in where you will continue your rehabilitation after your hospitalization. If you are going into the hospital for an elective procedure requiring hospitalization, it’s best to talk about some of these variables with your physician beforehand so you have a plan in place when you are discharged from the hospital. In this article I will address the major differences between the different rehab settings, medical qualifiers, and the Medicare coverage for each. 

Inpatient Rehabilitation Facilities

Inpatient Rehab Facilities (“IRF’s”) are generally either free-standing rehabilitation hospitals or rehabilitation units attached or inside a hospital. IRFs provide intensive rehabilitation, physician supervision and nursing care for serious surgeries, illness or injury. Patients must be able to tolerate up to three hours of therapy per day, five days per week. Services provided include, but are not limited to: 

• physical therapy; 
• occupation therapy; 
• speech therapy; 
• nursing care; and 
• physician supervision. 

Also, there are qualifying diagnoses that may cause you to require this level of care, such as: 

• stroke, 
• spinal cord injury; 
• multiple traumas;  
• bilateral total knee or hip replacement; 
• neurological diseases; 
• amputation; and 
• total joint replacements if you have a BMI at or above 50.

The entire team works in a team environment to coordinate and deliver intensive rehabilitation to patients with these serious diagnoses or conditions.

Medicare Coverage in an Inpatient Rehabilitation Facility

The IRF is the most intensive post-acute rehabilitation setting after a major illness, injury or surgery. You must have a qualifying diagnosis to participate. You also must be able to tolerate therapy three hours per day, five days per week from more than one rehabilitation discipline. Original Medicare does cover it, but the out of pocket co-insurance is the highest of all the post-acute rehab settings. However, most Medigap insurance plans will cover the co-insurance during your care. Out of pocket expenses may be higher for a Medicare replacement plan, so please check with your individual insurance plan.

If you qualify for coverage under Medicare in an IRF setting, it generally will cover the following:

• rehabilitation services;
• meals; 
• nursing services; 
• drugs; 
• semi-private room; and 
• other hospital services and supplies

Generally speaking, even if you have Medicare coverage in an IRF, you will pay the following costs out of pocket:

• Days 1-60: $1408 deductible if not already used in your acute hospital stay (as of 2020)
• Days 61-90: $352 co-insurance daily (as of 2020)
• Days 91 and beyond $704 co-insurance daily per each lifetime reserve day up to 60 days per lifetime, which includes any reserve days used in the acute care hospital
• After reserve days are used for the same illness, you are responsible for 100% of the cost
• Most Medigap insurances cover the co-insurances, so if you have one, please call and check

Skilled Nursing Facilities

Skilled nursing facilities (“SNF’s”) are post-acute nursing and rehabilitation centers which can either be a free standing facility, or an extended wing of a hospital or nursing home. This type of rehab setting provides 24 hour nursing care and rehabilitation as needed. This level of care generally is provided after a hospital stay of at least three days in duration. Typically the stay at an SNF can last anywhere from a few days to multiple weeks. The main difference between this type of facility and an IRF is the intensity of the rehabilitation. There isn’t a minimal requirement for therapy in an SNF, but instead, it’s delivered based on the need of the patient. In some instances, patients don’t receive any rehabilitation, only nursing services, depending on what their specific needs are. An example of a patient who might utilize this type of rehabilitation facility would be a unilateral hip replacement recipient. The patient might have difficulty controlling pain and be dealing with an incision infection in the hospital. This patient would typically require nursing care daily and some rehabilitation. If the patient lives alone and has to climb ten stairs to enter their home, a one or two week stay in an SNF would be appropriate so that the patient could receive rehabilitation to learn how to climb stairs safely and receive 24 hour nursing care for the wound infection. This patient likely would not be able to withstand the rigorous rehabilitation schedule provided by an IRF, but they also likely require nursing care and other assistance beyond the scope of that provided by an outpatient rehabilitation facility or home health care. An SNF would be the ideal rehabilitation for this patient before returning home alone or with home health.

Medicare Coverage in a Skilled Nursing Facility

For Medicare to cover rehabilitation care in an SNF, you must (i) be formally admitted as an inpatient to a hospital for three consecutive days, not including the day of discharge; (ii) enter an SNF within 30 days of leaving the hospital, and (iii) receive care for the same condition you were treated for in the hospital. You also must need skilled nursing care seven days per week or skilled therapy services five days per week, however, there isn’t a minimum time requirement like there is in an IRF, where you must be able to withstand three hours of therapy per day.  

If you qualify for coverage, Medicare would typically cover the following:

• nursing care; 
• meals; 
• medical social services; 
• dietary counseling; 
• medical equipment and supplies; 
• medications; 
• semi-private room; and 
• rehabilitation.

Even if you have Medicare coverage while in an SNF, you will be required to pay the following costs:

• Days 1-20: $0 for each benefit period or illness
• Days 21-100: $176 co-insurance per day
• Days 101 and beyond: you cover all costs, however, if you later begin a new spell of illness and have been discharged for 60 consecutive days, you will be eligible for an additional 100 days.
• Medigap insurance plans usually help to cover the co-insurance, so please call before your procedure

The SNF is the ideal post-acute rehabilitation facility if you require both rehabilitation services and nursing care, but you don’t require intensive rehabilitation of three or more hours per day and you don’t require close supervision of a physician. This type of facility should be a short-term stay in duration, if your stay is following a typical orthopedic surgery. However, for more complicated cases with comorbidities, the stay could be much longer. Common examples which might require a stay in an SNF would include: 

• unilateral knee or a hip replacement if you have stairs at home and live alone; 
• a minor stroke; or 
• recovering from an illness that required a moderate hospital stay if you still need daily nursing care and some rehabilitation to regain your independent function.

Home Health Care Rehabilitation

Home health rehabilitation is usually a great fit for the person who no longer needs high level care in a hospital, IRF and SNF, but still requires part-time nursing and/or rehabilitation. A perfect example of this is someone who had a total knee replacement, has someone at home to assist with basic tasks and no problematic environmental issues at home like stairs. This person could be discharged from the hospital directly to home health care with a nurse checking on the incision and their medications and a therapist coming in a few days per week. Home health rehabilitation has the resources to send whatever rehab professional this person may need, such as a physical therapist, occupational therapist or speech therapist. The goal here is to utilize home health rehabilitation until you no longer require nursing care and then be transferred to outpatient rehabilitation as soon as you feel comfortable leaving your home. For people who have someone to drive them, this may mean they only need home health therapy for a few visits, but for people who drive themselves, it may take a little longer before they are able to drive to an outpatient clinic depending on the severity of their injury. Many studies have shown that people heal better in their own home environment and there is less of a chance of contracting a hospital or facility-acquired infection.

Home health care is often a great option if you don’t require daily nursing care or if you don’t need nursing care at all, but you need some rehabilitation. This is the bridge service getting you ready for outpatient rehabilitation. The big issue over the past few years is that home health rehabilitation has arguably been over-utilized for extended time frames, rather than being implemented as needed as a bridge service. Generally most patients prefer home health rehabilitation because Medicare pays for 100% of the cost and it is convenient. However, the rehabilitation provided in your home is really basic compared to that provided at an inpatient or outpatient rehabilitation facility. Generally speaking, the sooner you get to outpatient rehabilitation, the faster your recovery will progress. Outpatient clinics have many more resources at their disposal than you have in your home, which ultimately speeds up your recovery and helps you achieve your desired goals. 

Medicare Coverage for Home Health Rehabilitation

To receive Medicare coverage, the home health rehabilitation must:

• be prescribed by your physician;
• require part-time skilled nursing care or physical or occupational therapy; and
• you must be confined to your home by an injury or medical condition.

If you qualify for Medicare coverage, it will generally cover the following:

• 100% of part-time skilled nursing care, usually two to three visits per week;
• physical, speech and occupational therapy, usually two to three days per week;
• medical supplies; and
• home health aides if you are receiving any of the above.

Outpatient Rehabilitation Services

Outpatient therapy is provided in a private practice, hospital outpatient clinic or even some SNF’s have outpatient clinics. If you require more than one service such as physical therapy and occupational therapy, you will probably need to go to an outpatient hospital clinic, because most private practice clinics only have one service. The amount of therapy you will receive will depend on your condition and your needs. The therapist will perform an evaluation on your first visit to determine your needs and develop a treatment plan dependent on your potential and goals. Typically outpatient therapy is provided two to three days per week, but with certain conditions, more therapy may be necessary. Each visit is generally 30 to 60 minutes in duration.

Outpatient therapy is often the perfect setting for a person who has the ability to leave their home and travel to a clinic for therapy, but doesn’t require the care of a nurse. A good example of this would be the person who had a total knee or hip replacement, minor stroke, broken arm or leg and returned home. After returning home, they likely received home health therapy for about two weeks and now can drive and leave the house. Also, if you don’t require any nursing care and can get to the outpatient clinic upon discharge from the hospital, you can skip home health altogether and start your outpatient therapy right away. Outpatient rehabilitation clinics have more high-tech equipment that can be utilized in your rehabilitation, such as: 

• exercise bikes; 
• aquatic therapy; 
• weight machines; 
• ultrasound;
• electrical stimulation; and 
• traction. 

These types of equipment combined with the more intense levels of therapy being available typically will allow you to progress faster and achieve your goals in a more timely manner.

Medicare Coverage for Outpatient Rehabilitation

In order to qualify for Medicare coverage for outpatient rehabilitation, you will need to meet the following requirements:

• You will need a plan of care signed by your physician at-least every 90 days or sooner dependent on the therapist’s plan;
• The therapy provided in the case of a rehabilitation patient must meet the medical necessity requirements, which means they have the potential to improve;
• In the case of maintenance therapy, you may have periodic therapy to help maintain your current condition or prevent you from regressing.

If you qualify for Medicare coverage for outpatient rehabilitation, Medicare will provide the following coverage:

• Medicare covers 80% of the cost after your $198 (for 2020) deductible has been met. Most people have a secondary insurance that picks up the remaining. If not, the cost will generally be anywhere from $10 to $30 depending on the services you receive.
• If you have a Medicare replacement plan, please call your plan to learn more about your benefits. Most replacement plans require significant co-payments.

Wrapping it All Up

In conclusion, you have four rehabilitation setting choices following a hospital stay for an illness, surgery or trauma. The setting that is best for you depends on multiple variables outlined in this guide. If you have an elective surgery planned and expect to be in the hospital for a short stay, please discuss your rehabilitation preferences with your physician rather than waiting until after the procedure. Taking an active role in your care is always the best option. The IRF will generally be your best option if you need intensive rehabilitation, nursing and physician supervision. The SNF will be a good option if you need 24 hour nursing supervision and/or rehabilitation. Home health rehabilitation is may be your best bet if you need a nurse intermittently or don’t need nursing care, but need some low intensity rehabilitation. Finally, outpatient rehabilitation is likely the best option once you can physically leave your home and get to the clinic and no longer need nursing help at home. There are plenty of options based on your individual needs and condition. Stay informed and be proactive with your care. Good luck with your recovery!