Layman’s Guide To Post Acute Care

I had a conversation with a friend today who has a relative that is comatose after a surgical procedure.   The patient has recently been shifted from a feeding tube though the nose to one connected to the stomach and is about to be transitioned from oxygen through a breathing tube to a ventilator connected directly to the throat via a tracheotomy.   This progression is typical for someone who is unable to eat or breath on their own because temporary breathing and feeding tubes over time begin irritate the throat and must be replaced with more direct connections.     Once these more permanent breathing and feeding connections are completed, the patient will likely be transitioned from an ICU to a transitional care unit within the hospital and then the hospital and Medicare or a private insurer will likely soon want the patient relocated to from the hospital, which is designed to provide short-term acute care.

While hospital discharge planners or social workers and the patient’s health insurance provider may all have suggestions or recommendations or preferences about where the patient’s post-acute care should be provided, under Medicare and some types of private health insurance the family will have a choice about where post-acute care is provided.    This short guide summarizes the options to help you achieve the best result for a loved-one at a stressful time for all concerned.

Types of Facilities – There are four types of post-acute care options, which are typically stand-alone facilities but can also be co-located within a general acute care hospital in some cases.   The four types of post-acute care facilities are:

  1. Rehab Hospital, also called an IRF- Inpatient Rehabilitation Facility
  2. Long Term Acute Care Hospital, LTAC, sometimes LTACH
  3. Nursing Home, also called a SNF – Skilled Nursing Facility or in some cases a Transitional Care Facility, which is essentially a SNF located within a hospital
  4. Hospice, which can be provided in a specialized hospice facility, within a SNF or other medical facility or in someone’s home.

A Rehab Hospital or IRF is designed to provide post-acute care for patients who require and are physically able to participate in a minimum of three hours a day of physical therapy (PT), occupational therapy (OT), and/or speech therapy at least five days per week.   Requirements for IRFs call for registered nurse (RN) oversight and availability 24 hours a day and between five and seven and a half nursing hours per patient per day, while the standard for nursing homes is usually between two and a half and four nursing hours per patient per day.   IRFs are also going to have regular physician visits and supervision and extensive rehabilitation gyms and specialized rehab equipment and staff.     So IRFs generally offer a higher level of care than nursing homes but only those patients who are able to handle at least three hours of therapy per day are able to transition to a IRF.   Medicare and most private insurers will pay for IRF care for patient who needs and can tolerate relatively intense therapy following an episode of care in a general acute care hospital.

A Long Term Acute Care Hospital (LTAC) is licensed as a acute care hospital but is designed to care for patients with a 25 – 30 day average length of stay versus less than 5 days in a general acute-care hospital.   Typical LTAC patients have multiple co-morbidities, multi organ system failure, and significant loss of independence, most following a traditional hospital stay.   LTACs are designed to care for critically ill patients who require specialized, aggressive, goal-directed care over an extended recovery period.   So patients on feeding tubes, with tracheotomies and complex, difficult to treat medical conditions are well-suited for care in an LTAC provided there are expectations that the patient’s condition can improve or that their condition needs to be stabilized before stepping down to another setting offer less intense care, such as a SNF or home healthcare.  Medicare and most private insurers will pay for LTAC care for medically complex patients who need ICU level care for an extended period following an episode of care in a general acute care hospital and have some prospect for recovery or being stabilized so they can ultimately be cared for at home or in a SNF.

A Nursing Home or Skilled Nursing Facility (SNF) in most cases offers two types of care.    One is true post-acute care that includes therapy services similar to what is provided in an IRF and some may accommodate complex patients including patients with tracheotomies similar to what may be provided in an LTAC.   Some nursing homes have extensive rehab gyms and therapy staff and will have 24/7 RN care and attending physicians.  But not all nursing homes provide post-acute care services or take medically complex patients and requirements for nursing hours and physician supervision are typically lower in a SNF than an IRF or LTAC.    Nursing homes also offer longer-term nursing care, sometimes call custodial care, for patients who have health conditions that require enough nursing care to make care at home infeasible or who do not have a home or family situation that will allow care at home.    Custodial patients may staff for years and there is little expectation that they will recover and return home.    Medicare and private insurers will generally pay for a limited period of post-acute care in a SNF following an episode of care in an acute care hospital.  But the amount of time for which Medicare will fully cover SNF care is 20 days, after which a co-pay kicks in, and Medicare will not cover long-term custodial care for a patient who is not making progress toward recovery.   For patients without long term care insurance the only option for paying for long-term custodial care in a SNF is Medicaid, which generally will only cover payments after all of a patient’s own funds are exhausted.

Home Healthcare is non-facility based option that provides post-acute care for some patients.   It can deliver wound care, PT, OT and speech therapy and other types of skilled care but will not provide 24/7 patient monitoring and generally requires support from family members in order for this to be a viable option immediately following a general acute care hospital treatment.   Home healthcare often comes into the picture is to provide followup therapy or nursing care after a patient transitions from an IRF, LTAC or SNF to home but is only relatively healthy patients with supportive living situations and families are typically able to get all of their post-acute care from home healthcare.   Medicare and private insurances will pay for home healthcare but only for specific skill nursing and therapy services.

Hospice Care provided in a specialized facility, within a senior housing, nursing home or other health facility, or in one’s own home, is intended for patients who are expected to live for six months are less.    The care is design to keep the patient comfortable and free from pain and to help family member cope with a loved-ones impending death.   While most healthcare providers are reluctant to conclude that additional medical treatment will not allow a patient to get better, hospice care is a very good option once the family and their healthcare providers reach this conclusion.  Medicare and most private insurers will pay for hospice care in a variety of settings.

Deciding Where a Love-One Should Receive Post-Acute Care – Important factors to consider include: the type and level of care the patient needs, the quality and location of the facility.     The type of care that each facility offers is summarized above and you can discuss the appropriate placement with the care team at the hospital including your physicians, nurses, discharge planners and social workers who usually take primary responsibility for transitioning a patient to post-acute care.    There is a tendency to favor facilities offering the highest level of care, such as an LTAC or rehab facility over a nursing home.   However, if the patient will does not need or will not be able to tolerate the level of therapy these facilities can provide it may be better to to directly to a nursing home rather than spend a few days or a week in another type of facility and have to move the patient a second time.    Many patients will prefer home healthcare to facility-based care but it is important to be realistic about whether the physical conditions of the home and the amount of support family members can provide make this the best first post-acute care option.    Location matters because it is important for family members to visit during what may be a multiple week or month period of post-acute care and family members are more likely to visit if a facility is conveniently located.     Finally, quality can be assessed by visiting a facility, speaking with discharge planners and social workers, checking online (The Centers for Medicare and Medicaid Services (CMS) has a 5-star quality rating system that isn’t perfect but can help – and in the case of skilled nursing, check with the state Office of Aging ombudsman about any prior complaints.

It will be much easier to evaluate and find space in a facility of your choice if you start looking before your loved-one is about to be discharged.    However, if you need more time it is possible to appeal a hospital discharge and generally buy yourself one-three days if you need more time to evaluate and decide upon your best option for post-acute care (see appeals on the website).

Relationships Key to Happiness In Retirement & Seniors Housing

I spent a recent weekend on the Rhode Island shore with a eight friends I have known for over 40 years and several of their spouses/significant others.     We try to get together every two or three years and it is amazing how quickly we are able to reconnect and how reminiscences we have all been over many times before are still a pleasure to hear.

This weekend experience reminded me of the importance of relationships – with a spouse or significant other, with your children and family and with friends and neighbors – for happiness.     I believe the importance of relationships in making us happy is too often overlooked when seniors contemplate a move from work to retirement, in relocating to a new location for all or part of the year, and in thinking about and executing a move to a seniors housing community.

Relationships In Retirement – One important aspect of moving from full time work to full time retirement is that many of our friends and social relationship revolve around our work.   We all have business colleagues inside or outside our organizations that we interact with socially as well as professionally for lunches, dinners, conferences and meetings, charity events, golf and other activities.   These relationships are hard to maintain when you no longer see these colleagues on a regular basis.   If you want to maintain these relationships you, as the retiree, will have to work hard to maintain active contact with former colleagues.

Even if you make the effort to keep connected with former colleagues, many of these work-connected relationships will slip away when you retire because you simply won’t be moving in the same circles as former colleagues.   To supplement these relationships, you need a plan of action to build alternative social relationships, particularly some that are intellectually stimulating.

Once you do retire, some of the most significant challenges you encounter in your social relationships may involve your spouse, significant other, children and other family members.   The relationship with your spouse, if you are married, may be the most important post-retirement relationship you have.   But the nature of your relationship with you spouse may change dramatically as one or both of you has more time at home and you negotiate new responsibilities on household chores, financial management, planning vacations and social activities.     It is important to anticipate and discuss these changes in advance and to maintain an active dialogue as you settle in to your post-retirement lifestyle.

Relationships with children are another important aspect of happiness for retirees but can also create challenges.   Children may live far away, may want more of your time for childcare than you want to give or may not want your advice or help now that you have more time to offer it. For many of us baby boomers our retirement may coincide with our children marrying, getting traction in their careers, establishing families and generally feeling more independent from parents and less in need of parental advice. It is important for the parent/retiree to be sensitive to these changes in roles and to adapt to changing conditions.   It is also important to let your children know if you believe they are claiming more of your time for childcare or other responsibilities than you want to give.

Relationships As We Age – Another aspect of relationships that I believe is very important for happiness and underappreciated as we age is the loss of connectivity to others as your mobility and that of friends is reduced, you or friends relocate to new locations or a spouse or other close friends die.     Many seniors face a gradual narrowing of social relationships and human interaction for the reasons just noted.     Most of the literature that discusses a senior moving to senior housing, including a July 10, 2015 New York Times article entitled “Team Effort In Making Decisions on Elder Housing” focus on a senior’s cognitive and physical abilities, as well as financial considerations, in determining when a move from a home to seniors housing is appropriate.   I believe an equal or more important reason to consider seniors housing, and one that I believe is a good predictor of future health, is a senior’s social network and level of social interaction.   If a senior has lost a spouse, has a shrinking network of social relationships and has very little interaction with peers, family or friends when living at their home or apartment, I believe a move to seniors housing should be actively considered as a way of putting a senior in a position to re-establish meaningful social relationships and interactions.  It may be appropriate to adopt for seniors the same rule I recently saw advocated for children – if they are spending more than two hours a day in front of a screen, be it TV, PC, videogame or tablet it may be time to examine their level of social interaction consider intervention.

I believe there are also practical advantages to discussing a senior’s potential need for seniors housing in terms of social interaction, rather than cognitive or physical limitations.   In the discussion of social interaction, there is a presumption and a focus on a senior being alert, active and in need of human interaction rather than a focus on declining mental and physical abilities.   A move to a senior housing community to make new friends and increase social interaction is a much more positive discussion than a move to prevent falls or keep a senior from harming themselves through mental lapses.   It is also a discussion that can and should happen sooner in a senior’s life when they will gain much more out of a move to a seniors housing facility and before a life incident forces consideration of a move under crisis conditions.

In a future blog, I will discuss the challenges to fitting in and establishing positive social interaction after a move to seniors housing based on some recent industry research.



Technology In Seniors Housing

Stereotypes view anyone over 50 as barely able to keep up with technology and unable to use smartphones, Skype or Netflix. But technology already plays an important role in the lives of many seniors, even those over 75. It is reshaping the ways seniors live and interact in their homes and within senior housing communities.

Today, most senior housing communities offer wifi access to residents and many provide a computer center and computer training and support for residents.    Wii and other gaming systems are widely used for bowling and other socially and physically engaging activities.  But the use of technology to enhance resident’s lives and improve the quality and efficiency of care delivery is still in its early stages.

I strongly believe the use of technology will continue to grow in seniors housing, particularly as the baby boom generation, now 51 to 69, age into seniors housing.   The baby boomers were the first generation to being interacting with computers during their school years and are generally much more comfortable using technology than the Roaring Twenties and Depression Era babies using technology in senior housing communities today.

Much has been made of the ability of technology to enable a greater proportion of old, frail seniors to living independently and I believe we will see continued progress in this area. But I also see technology increasingly being used within senior housing communities to enhance 1) communication and interaction, 3) engagement, 3) evaluation and 4) mobility.

Communication and Interaction

FaceTime, Skype and similar services are a vital link between grandparents and grandchildren and may be the biggest single driver spurring current senior housing residents, generally 75 years of age or older, to use smartphones and computers.   These same tools, along with more conventional email, are now and will increasingly be used to link adult children and other family members with senior housing residents and, for the savvy senior housing operators, to link adult children with caregivers and administrators to get more timely and more interactive information on how their loved ones are faring in senior housing communities.   These same tools will also become an increasingly important link between senior housing communities and other caregivers outside the community, including physicians and hospitals.   Healthcare IT and data interoperability among facilities and caregivers is still in its infancy but some forward thinking operators are building data links between their facilities, hospitals and other healthcare providers.   The goal here is to improve communication, reduce unnecessary hospitalizations and adverse drug interactions but the technology also has the potential to greatly improve communication with seniors themselves and with their families regarding healthcare issues.


Use of Wii and other video games to engage seniors socially and mentally barely crack the potential of technology to enhance engagement and mental stimulation for seniors, who often feel isolated in senior housing facilities today.     Why not use technology to deliver high quality courses, concerts, yoga and other activities with better trained and more professionally produced programs than are possible with local volunteers and on-site staff.   Most senior housing residents in my observations are bored in their communities and would welcome more stimulating programming that technology can likely deliver better and less expensively.   There is also emerging technology, such as robots of various types, that has the potential to engage residents much more actively and much more regularly than can be done today by human staff.   As the cost of this technology declines, a robot companion for every resident that wants one is a realistic near-term possibility and robots, in addition to engaging residents directly, could also offer video links to family members and care givers and friends potentially in a more seamless way than is possible with current smartphone and computer software.

While I was on vacation this past month, there was an article on July 2, 2015 in the “Personal Journal” section of the Wall Street Journal about a dating service for seniors started by the Hebrew Home in Riverdale to connect its residents.   While this dating service appears to be more staff than technology driven, it points out another potential use of technology for engaging senior housing residents that even most professionals working in the field would not have considered.


Seniors housing facilities are regularly evaluating residents to determine what level of services and support is appropriate and a range of caregivers inside and outside senior housing facilities are regularly evaluating seniors mental and physical conditions to ideally adjust care and medications levels to avoid falls and other adverse health conditions.   Technology is emerging, including devices such as the Apple Watch and Fitbit, to monitor various health parameters.   To date this technology has been focused on younger, healthy, tech savvy adults, not seniors.   But I see significant opportunities for seniors’ health conditions to be monitored in greater detail in real time in an unobtrusive manner and to alert caregivers when key vital signs, like blood sugar or blood pressure, deviate from established norms.   Using technology to monitor cognitive ability on a regular basis is already possible via online tests and will be using increasingly in seniors housing communities, I believe.    Also, as noted above under communication, some degree of remote patient assessment and diagnosis is already happening in some senior housing communities as on site staff reach out to on-call physicians or nurse practitioners. Expanded use of remote technology for resident healthcare evaluation has the potential to significantly enhance the ability of facilities to address resident needs without resorting to an ambulance call or hospital visit.


An entrance fee CCRC in Baltimore, near where I live, recently added a Zipcar site in its parking lot.   The service is available to residents and staff and has the benefit of reducing demand for parking from seniors holding on to their cars, improving mobility options for residents still able to drive and for staff, many of whom rely on public transportation to get to and from work.   I haven’t seen details about how Zipcar may qualify seniors to drive its vehicles but this concept seems to be to offer greatly enhanced mobility options for seniors and staff.   The other options that I see significantly enhancing mobility options for seniors are Uber and Lyft type services, which can provide much better and more flexible mobility options for senior housing residents that the typical senior housing facility van.   Seniors are already using Uber and Lyft from their homes but I have not yet seen senior housing communities formerly engage Uber and Lyft in lieu of or in addition to offering the conventional van. Nor have I seen these services target senior housing communities by training drivers to deal with senior residents or equipping vehicles with handicapped access but these accommodations would seem to offer great potential to enhance senior housing resident mobility. I believe there is a significant opportunity both for Uber and Lyft and for senior housing operators to develop a ride sharing service specifically designed for and targeted to seniors living on their own and in senior housing facilities.

Guidance for Operators

It is unlikely in my view that grand integrated technology solutions will appear for communication/interaction, engagement, evaluation and mobility.   Rather innovation by operators and technology companies will likely create technology to address specific issues and operator will be left to integrate these into their operations. The best way for operators to prepare for new technology, in my view, is to build innovation and experimentation into their operations, working with small groups of staff or individual properties.   Try things, some will work, some won’t but over time technology offers the potential to significantly enhance the resident experience in seniors housing and to increase care quality and delivery.   Operators able to innovate will be able to differentiate themselves from competitors and offer services that will not be available in seniors’ homes.