After a hospital stay, your physician or case manager may recommend you transition to another care setting as part of your recovery. These settings—known as post-acute care—include home health, inpatient rehabilitation, skilled nursing homes and long-term acute care hospitals.
Should you need additional care, your care team could refer you to one of these settings based on your abilities and goals, but as a patient, you have a choice in choosing which facility you go to. In fact, it is your right as a patient. The Center for Medicare/Medicaid Services refers to this as patient choice.
What Does Patient Choice Mean in Medicare?
In 2019, the Center for Medicare/Medicaid Services updated its discharge planning rules to require providers to inform you of your choices when it comes to your post-acute care options.
Your referring clinicians—typically a physician and/or a case manager—are required to inform you of the different care settings available in your area that are appropriate for the level of care you require. They also have to tell you if they or their organization have any financial ties to those listed and to share information from those providers so you can make an educated choice.
The information they share should be related to your recovery goals. Depending on the setting of care, some of that information could include data surrounding rehospitalization (the need to transfer back to the acute care hospital) and patient satisfaction scores, as well as discharge to community rates.
While all this information can be empowering, it can also be overwhelming, especially if you are not familiar with the different settings of post-acute care.
Know Your Options before You Need Them
As defined by the Medicare Payment Advisory Commission, post-acute care is rehabilitation or palliative care that a patient receives after a stay in an acute care hospital, or in some instances, in lieu of a hospital stay. That care can take place in the home or in a facility, depending on the patient’s needs. Medicare recognizes four primary types of post-acute care:
- Home health: Home health is care that is provided in the home to help you recover after an illness or injury. Your doctor or other provider can refer you to home health and work with you and the agency to determine how many visits you are eligible to receive each week. Home health is designed to meet you where you are. If you’re recovering from a surgery or a recent hospital stay or managing a disease or injury, home health provides care in the comfort of home. Home health services include nursing, therapy, nursing aides and social workers.
- Inpatient rehabilitation: Inpatient rehabilitation provides a hospital level of care with intensive therapy to help you regain your independence and ultimately return to your community after an illness or injury. While at an inpatient rehabilitation hospital, you will receive three hours of therapy a day, five days week. You will also have frequent visits from a rehabilitation physician and other physicians, depending on your needs. Nursing care is provided around the clock, and a multi-disciplinary team that includes rehabilitation physicians, nurses, therapists, dietitians, pharmacists and case managers will design a unique care plan to fit your goals. Conditions commonly treated at rehabilitation hospitals include stroke, head or spinal cord injuries, neurological disorders such as Parkinson’s and multiple sclerosis, amputation and hip fractures.
- Skilled nursing facility: At a skilled nursing facility, you will receive therapy and nursing care. However, unlike inpatient rehabilitation facilities, there are no legal requirements mandating the number of hours of care per day that must be provided. Physician visits are not as frequent, either.
- Long-term acute care hospital: If you or your loved one has had a particularly extended and medically complex hospital stay, a long-term care hospital may be recommended. At a long-term care hospital, you will receive nursing and rehabilitation care for an extended period of time. Many patients referred for this level of care are not yet able to participate actively in rehabilitation and may require assistance breathing.
Will My Insurance Cover It If I Choose a Different Setting/Provider than Recommended?
That depends on your insurance and your coverage. You do have to meet certain medical requirements for the different settings of care to receive Medicare coverage. Also, some Medicare plans, such as Medicare Advantage ones, limit you to providers within their network. Work with your care team or primary care physician to determine if you meet the requirements of a particular setting. Make sure to discuss your goals, so they can fully understand your long-term needs and the setting that will best help you meet them. In some circumstances, you can consult with your preferred provider to see if they can work with your insurance to help you receive coverage.
Do Your Research
Your care team is required to provide you and your loved one with data concerning the quality of care of providers in your area, but take time to do a little research yourself. Look at patient reviews on websites. Ask family and friends with similar conditions who have had good outcomes and experiences. Where and who you receive care from matters, so take time to look around and find the best provider to help you reach your recovery goals. Perhaps a family member can tour a facility you are considering or take a virtual tour online. By understanding the different settings of care now, you are already taking a step in the right direction.