Navigating Postacute Care Options for Patients After Hospital Discharge: A Review

Approximately 25% to 40% of hospitalized adults are discharged to receive postacute care (PAC) either at home through home health (HH) or in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or long-term acute care hospitals (LTACHs). An overview of various PAC settings is needed to help hospital-based clinicians collaborate most effectively with patients, caregivers, and an interdisciplinary care team to promote high-quality PAC and facilitate better PAC transitions.

PAC settings vary in their eligibility requirements and in the intensity and complexity of services they provide. HH provides intermittent in-home support for homebound individuals with skilled needs. SNFs provide housing, daily nursing care, rehabilitative services, and medical supervision, although the medical care provided is often a dramatic step down from hospital-based acute care. IRFs provide intensive rehabilitation, most commonly for individuals with specific diagnoses (eg stroke, hip fracture, or spinal cord injury). LTACHs care for patients with medically complex conditions who require prolonged hospital-level care for services (eg, ventilator weaning, complex wound management). Discharge planning to PAC should be guided by clinical needs, caregiver support, and the values and preferences of patients and caregivers; yet it is often opaque and influenced by external factors such as insurance coverage and geography. Clinicians should proactively recognize PAC needs, advocate for specific PAC settings for targeted situations, and assist on selecting an appropriate PAC facility, especially for patients with insurance restrictions. Moreover, PAC admissions frequently represent a pivotal time period for individuals with serious illness, during which a subsequent poor prognosis becomes clear. Therefore, PAC stays represent an opportunity for clinicians to revisit prognosis with patients and caregivers, engage in goals of care conversations, and clarify plans for the future.

To provide patient-centered care and help facilitate better transitions for patients and caregivers, hospital-based clinicians have a responsibility to understand the different types of PAC settings and actively participate in discharge planning.