2.3 Post-Acute & Long-Term Care (PALTC)
2.3.1 Definitions
According to The Society for Post-Acute and Long-Term Care Medicine (2022), the following terms are associated with the post-acute and long-term care (PALTC) continuum:
Assisted living is a living environment focused on maintaining independence in a supervised setting. Many assisted living residents live in communities with apartments and amenities such as group dining and medication assistance. Assisted living is not regulated by the Federal government.
Geriatrics is the branch of medicine dealing with the care of patients 65 and older.
Hospice care is focused on providing comfort and pain control versus extending one’s life for patients expected to live six months or less.
Inpatient rehabilitation facility is a specialized hospital or unit focused on delivering intensive rehabilitative services to patients with medically complex diagnoses. It is intended for those likely to benefit from and who can tolerate a plan of care that includes more than three hours of therapy each day.
Long-term care is traditionally provided in nursing homes, providing patients who can no longer be cared for at home or in assisted living with support for both daily living activities and complex medical problems.
Long-term care hospital is an inpatient facility for those demonstrating a great deal of medical complexity and requiring an extended period of medical care and hospitalization. These patients are contending with multiple acute and/or chronic comorbidities, necessitating a higher level of care.
Palliative care focuses on managing the chronic conditions of a patient with the goal of providing comfort and the highest quality of life possible.
Post-acute care typically refers to care provided to patients recently released from the hospital and can take place in many settings, including nursing homes and rehabilitation centers.
Skilled nursing facility care is care ordered by a physician, delivered by skilled nursing or therapy staff, and paid for by Medicare Part A for a fixed period of time (up to 100 days). Skilled care takes place in a nursing home and may or may not be the same as post-acute care.
The two sections below (2.3.2 and 2.3.3) review two levels of care: Post-acute care and long-term care. Examine how some facilities, such as a skilled nursing facility, can be utilized in both levels of care.
2.3.2 Post-Acute Care
Post-acute care (PAC) is a broad term that covers a wide variety of service offerings and settings. In a review of post-acute practices, Wang et al. (2019) noted that in the United States the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the American Healthcare Association (AHA) consider PAC to be:
Integrated inpatient care is directed at persons with all acute illnesses, accidental injuries, or serious diseases. It involves goal-directed treatment, does not depend on advanced technology, testing, or complex diagnostic procedures, and provides patients with alternatives to acute inpatient treatment after their acute conditions have stabilized by dealing with one or more specific, complex medical conditions or providing complex technical treatment.
The goal of returning patients back to the highest level of function possible is what sets PAC apart from treatment in other phases of the continuum. This goal requires integration or partnership with other acute and post-acute providers to ensure patients are placed in the proper care setting based on their individual needs. These needs are primarily defined as rehabilitative or palliative in nature following a stay in an acute care setting (Medicare Payment Advisory Commission [MedPAC], 2020). As with health services in general, PAC services exist along a continuum defined by the medical necessity for care the patients require. Post-acute care services are delivered in long-term acute care hospitals, rehabilitation facilities, skilled nursing facilities, and home and outpatient settings.
I. Long-Term Care Acute Care Hospitals
Most people who need inpatient hospital services are admitted to an acute‑care hospital for a relatively short stay. However, some people may need a longer hospital stay. Long-term acute care hospitals (LTACH) are certified as acute‑care hospitals, but LTACHs focus on patients who, on average, stay more than 25 days. Many of the patients in LTACHs are transferred there from an intensive or critical care unit. LTACHs specialize in treating patients with more than one serious condition but who may improve with time and care and return home. LTACHs generally provide services like respiratory therapy, head trauma treatment, and pain management (Centers for Medicare & Medicaid Services [CMS], 2019).
The goals for the LTACH setting are to rehabilitate patients to a sufficient extent so they may be transitioned to another level of PAC or to provide long-term services (potentially into perpetuity) for those requiring it. Therefore, admission is based on the complexity of the patient’s needs. Specifically, patients must have a level of medical or respiratory complexity requiring daily physician oversight and intervention. Typically, patients in this setting are ventilator dependent and receive various types of intravenous therapies (e.g., dialysis, antibiotics), nutritional support, external telemetry monitoring, and wound care management. Due to this complex mix of care, patients receive 24-hour nursing care, and all providers are required to have advanced cardiovascular life support (ACLS) training. Given all the potential medical and physical challenges for patients admitted to LTACHs, the average length of stay is typically greater than 25 days.
II. Rehabilitation Facilities
Rehabilitative care aims to cure, improve, or prevent a worsening of a condition. Examples are physical, occupational, speech, and other therapies following a stroke or physical therapy following orthopedic replacement surgeries such as hip or knee. Rehabilitation settings include outpatient centers, inpatient rehabilitation departments, freestanding rehabilitation hospitals, departments in subacute care facilities and nursing homes, and home care (Shi & Singh, 2019). However, the proportion of rehabilitation services that occurs in each of these settings is unknown.
Inpatient rehabilitation facilities (IRFs) are specialized hospitals or units focused on the delivery of intensive rehabilitative services to patients with medically complex diagnoses. It is intended for those who are likely to benefit from, and can tolerate, a plan of care that includes more than three hours of therapy each day. IRF teams focus on returning patients to their highest level of function following a major illness, accident, or injury. IRF care is delivered by multidisciplinary teams and includes physical therapists, speech-language pathologists, and occupational therapists who work together with physicians, nurses, pharmacists, and other care team members to achieve this goal. Patients in IRFs require 24-hour medical and nursing observation during their stay. Attending physicians specializing in physical medicine and rehabilitation (e.g., Physiatrists) lead the IRF care teams and are on hand to manage any unforeseen medical issues that arise during a patient’s stay.
III. Skilled Nursing Facilities
Skilled nursing facilities (SNFs) provide services similar to IRFs but do so in a more home-like, less intensive setting. These facilities are licensed by the states to ensure a safe and suitable environment is maintained for those receiving care. SNF patients typically require more mild or moderate levels of care and receive one to two different types of therapy during their stay. Before admission, SNF patients must also complete a minimum three-night stay in an acute care facility. The key criteria for choosing a SNF is for caregivers to assess whether a patient is ready to return to a more independent environment. They may no longer require the services of an inpatient hospitalization, but they are not yet ready to take on their own care at home. For example, following a stroke or musculoskeletal injury, a patient (and their caregiver) may not feel confident in their ability to complete activities of daily living (e.g., dressing, stair climbing, medication management). They don’t necessarily require daily physician or nursing care, but they still need some clinical support and additional therapeutic support before they are ready for their return home. A stay in a skilled nursing facility is designed to assist the patient as they gain the functional capability they need for a successful return to more independent living. The treatment received in the SNF serves as a means to bridge the gaps in function that remain.
Upon admission to a SNF, patients receive a physical evaluation from an attending physician and therapists. From this evaluation, a treatment plan is established. Like IRFs, the care is delivered in a multidisciplinary fashion, but it may not be as comprehensive and likely does not include the same level of technology. Patients work on activities of daily living to prepare them for their ultimate return to their home setting. Dressing, bathing, eating, and other routine activities are simulated to help patients compensate for any long-term deficits they may be experiencing due to their illness.
Table 1 compares the description, treatment, providers, and length of service for three types of post-acute care facilities:
Table 1 Post-Acute Care Facilities
| Inpatient Rehabilitation Facility (IRF) | Long-Term Acute Care Hospital (LTACH) | Skilled Nursing Facility (SNF) | |
|---|---|---|---|
| Description | Resource-intensive inpatient environment Patients receive intensive rehabilitation therapy Interdisciplinary care |
Medically complex patients who: -are unable to participate in functional therapy -with care, may be able to return home |
Patients with moderate impairment requiring skilled nursing services and limited therapy services Requires a minimum stay in an acute care setting prior to admission |
| Treatment | Upwards of 3 hours daily Therapy focuses on function for daily activities, such as: -mobility -memory -speech |
24-hour medical management, such as: -wound care -IV antibiotics -frequent suctioning |
Regular medical management, such as: -IV therapy -dialysis support -infectious disease -management -less intense/frequent -rehabilitation services |
| Providers | Physician/physiatrist 24-hour RN coverage Interdisciplinary therapy team |
Physician 24-hour ACLS-certified RNs Specialty therapists Case manager |
Non-daily physician supervision RN coverage 8 hours every 24-hour period CNAs provide nursing support |
| Length of Service | 10-15 days | 20-30 days | 14-21 days |
IV. Home and Outpatient Settings
The PAC phase of the larger continuum of care goes beyond inpatient admissions to IRFs, LTACHs, and SNFs. Patients often continue to need care to help them maintain the gains they have achieved and to continue making functional improvements. Following discharges to SNFs, the largest volume of PAC patients receive some level of service in their homes through a Home Health Agency (HHA). This group includes patients returning home following a stay in a clinical setting (e.g., hospital, LTCH, IRF, SNF) but who still require additional follow-up and treatment. Many patients accessing home healthcare might also have received care in ambulatory (i.e., outpatient) surgical settings. Since 2012, many orthopedic procedures have transitioned from traditional hospital surgical departments to ambulatory surgical centers. As a result, many patients find themselves completing their post-surgical recovery and associated therapy outside a traditional clinical environment. Home health providers are available to ensure these patients achieve the desired outcomes. According to a recent study published by United Health Group (2020), it is estimated that more than 50% of all orthopedic hip and joint replacements will be performed in an ambulatory setting, which increases the utilization of services provided by HHAs. This level of care is offered for more than post-surgical patients, and more than 11,300 HHAs provide support for homebound patients requiring wound treatment/management, help with assistive devices, IV drug therapies, and many other conditions (MedPAC, 2021).
Like the other levels of PAC, the amount of care a patient receives from an HHA is driven by their unique needs. HHAs typically provide service from one to three times per week for those who need it. Services are provided by therapists, nurses, personal care technicians, social workers, and even physicians in some cases. The primary goals for care from an HHA are to educate the patient to care for themselves and to feel confident with their functional independence following an illness, accident, or injury.
Non-hospitalized patients who can to travel from their homes, and require one to two different treatment modalities, can receive care in an outpatient or ambulatory setting. These encounters typically involve either therapy (e.g., physical therapy, occupational therapy, speech-language pathology), diagnostic imaging, pain management, joint protection, injury prevention, or some combination of services. Outpatient therapy is provided across a wide variety of venues, including nursing homes, hospital outpatient departments, physicians’ offices, and comprehensive outpatient rehabilitation facilities, and by HHA and private practice therapists (MedPAC, 2021).
2.3.3 Long-Term Care
Long-term care (LTC) involves a variety of services designed to meet a person’s health or personal care needs during a short or long period of time. These services help people live as independently and safely as possible when they can no longer perform everyday activities independently. Long-term care is provided in different places by different caregivers, depending on a person’s needs. Most long-term care is provided at home by unpaid family members and friends. However, it can also be given in a facility such as a nursing home or in the community, for example, in an adult day care center (National Institute on Aging, 2017a).
The Patient Protection and Affordable Care Act uses the term long-term services and supports (LTSS) and defines the term to include home and community-based services and facility-based settings. This broad range of personal, social, and medical services is provided in a multitude of locations, including private homes, adult day-care settings, residential care/assisted living facilities, and nursing homes. Most LTSS is delivered by unpaid family or friends, many of whom struggle to balance their care activities with employment and other family responsibilities (Spillman et al., 2014). This type of care is typically referred to as informal (i.e., unpaid) care.
However, paid LTSS provided by paraprofessionals is becoming increasingly important as the availability of family caregivers shrinks. Coming generations of older adults will have fewer children to provide care for, and more women in their 50s and 60s, who provide much of the care received by older adults, will work outside the home. LTSS encompasses a variety of health, health-related, and social services that assist individuals with functional limitations. LTSS includes assistance with activities of daily living (ADLs) such as eating, bathing, and dressing and instrumental activities of daily living (IADLs) such as housekeeping and money management over an extended period. The goal of LTSS is to facilitate functioning among people with disabilities.
I. Home and Community-Based Services
Home and community-based services (HCBS) are types of person-centered care delivered in the home and community. HCBS allow people with significant physical and cognitive limitations to live in their home or a home-like setting and remain integrated with the community. Services include skilled care, personal care (dressing, bathing, toileting, eating, transferring to or from a bed or chair, etc.), home-delivered meals, transportation and access, supported employment, home repairs and modifications, home safety assessments, and information and referral services (CMS, 2021). Three types of home and community-based services include home healthcare, adult day care, and the elderly nutrition program.
Home healthcare
Home healthcare is a formal, regulated program of care delivered in the home. It can include a range of services provided by skilled medical professionals, including skilled nursing care, physical therapy, occupational therapy, and speech therapy. In addition, home healthcare can also include skilled, non-medical care, such as medical social services or assistance with daily living from a highly qualified home health aide. To be eligible for the home health benefit under Medicare, the patient must be under a doctor’s care, with a plan of care that the doctor regularly reviews. The recipient must be homebound and unable to leave the home unaided without the possibility of risk. Sources for home healthcare funding include Medicare, Medicaid, the Older Americans Act, the Veterans Administration, and private insurance.
Adult day care
Adult day care is a group program designed to meet the needs of functionally and/or cognitively impaired adults and provide respite for family caregivers. Adult day care centers offer a wide array of services that range from basic health services, meals, and activities to intensive health services for those who might otherwise have to be in a skilled nursing center. In general, there are three main types of adult day care centers: those that focus primarily on social interaction, those that provide medical care, and those dedicated to Alzheimer’s care. Medicare does not cover adult day care. Medicaid will pay some amount toward adult day care in nearly every state, though the amount is often limited. Long-term care insurance may cover adult day programs, and some financial assistance may be available through a federal or state program like the Older Americans Act or Veterans Health Administration.
The elderly nutrition program
The Elderly Nutrition Program (ENP) was designed specifically to address problems of inadequate dietary intake and social isolation among the elderly. ENP is authorized by and receives funding under the Older Americans Act Nutrition Program (Congressional Research Service [CRS], 2014). Additional funding is provided through block grants, Medicaid waivers, and private donations. Services include both home-delivered meals (commonly referred to as Meals on Wheels) and healthy meals served in group settings, such as senior centers and faith-based locations for people aged 60 and older (CRS, 2014). In addition, the programs provide a range of services, including nutrition screening, assessment, education, and counseling. Nutrition services also provide an important link to other supportive in-home and community-based supports such as homemaker and home-health aide services, transportation, physical activity, and chronic disease self-management programs, home repair, and fall prevention programs.
II. Facility-Based Settings
At some point, support from family, friends, and local programs may not be enough. People who require help full-time might move to a residential facility that provides many or all of the long-term care services they need. Facility-based long-term care services include: board and care homes, assisted living facilities, nursing homes, and continuing care retirement communities. Some facilities have only housing and housekeeping, but many also provide personal care and medical services. Many facilities offer special programs for people with Alzheimer’s disease and other types of dementia (National Institute on Aging, 2017b).
Board and care homes
Board and care homes, also called residential care facilities or group homes, are small private facilities, usually with 20 or fewer residents. Rooms may be private or shared. Residents receive personal care and meals and have staff available around the clock. Nursing and medical care usually are not provided on-site (National Institute on Aging, 2017b).
Assisted living
Assisted living is for people who need help with daily care but not as much help as a nursing home provides. Assisted living facilities range in size from as few as 25 residents to 120 or more. Typically, a few levels of care are offered, with residents paying more for higher levels of care. Assisted living residents usually live in their own apartments or rooms and share common areas. They have access to many services, including up to three meals a day; assistance with personal care; help with medications, housekeeping, and laundry; 24-hour supervision, security, and on-site staff; and social and recreational activities, with exact arrangements varying from state to state (National Institute on Aging, 2017b).
Although assisted living costs less than nursing home care, it is still fairly expensive. Because there can be extra fees for additional services, it is very important for older persons to find out what is included in the basic rate and how much other services will cost. Primarily, older persons or their families pay the cost of assisted living. Some health and long-term care insurance policies may cover some of the costs associated with assisted living. In addition, some residences have their own financial assistance programs. The federal Medicare program does not cover the costs of assisted living facilities or the care they provide. However, according to Koop (2022):
Most states do offer some degree of financial assistance for assisted living through Medicaid programs. However, it’s important to note that Medicaid does not cover the cost of basic room and board the way it does for residents of nursing homes. The exact services that Medicaid covers within assisted living vary by state and the specific program a senior applies for. All states offer assistance paying for some degree of personal care services (ADLs), but the ways in which those services are administered differ widely. For example, some state Medicaid programs provide eligible seniors with personal care assistance but not in an assisted living residence. The fundamental services that most Medicaid programs will pay for in an assisted living facility include:
- Case management
- Personal Care services
- Homemaker services (e.g., meal preparation, laundry, light housekeeping)
- Transportation
- Personal emergency response systems
Nursing homes
Nursing homes provide a wide range of health and personal care services. Their services focus on medical care more than most assisted living facilities. These services typically include nursing care, 24-hour supervision, three meals a day, and assistance with everyday activities. Rehabilitation services, such as physical, occupational, and speech therapy, are also available. Some people stay at a nursing home for a short time after being in the hospital. After they recover, they go home. However, most nursing home residents live there permanently because they have ongoing physical or mental conditions that require constant care and supervision (National Institute on Aging, 2017b).
Rehabilitation is a key component for short-term stays funded primarily through Medicare or commercial insurers. Medicare does not pay for long-term or permanent stays in nursing homes. On the other hand, Medicaid covers both short-term stays and extended stays for seniors with limited assets and low income who have a medical need for this high level of care. This coverage and the eligibility requirements vary by state. Nursing homes may provide only long-term care, only short-term care for rehabilitation purposes, or both. In order to be certified by the Centers for Medicare & Medicaid Services, these facilities must meet strict criteria and are subject to periodic inspections to ensure that quality standards are being met.
Murphy (2021) states, “overall, there is a fair degree of overlap between skilled nursing facilities and nursing homes. However, the differences between them can be especially confusing, considering that skilled nursing is available in a nursing home setting. In general, a SNF is a short-term facility with medical specialists dedicated to various forms of rehabilitation, while a nursing home focuses on long-term care.”
Continuing care retirement communities
Continuing care retirement communities (CCRCs), also called life care communities, integrate different levels of service in one location. Many offer independent housing (i.e., houses or apartments), assisted living, skilled nursing care, and memory care all on one campus. Residents can move from one area to another based on the level of service needed and stay within the CCRC. For example, residents who can no longer live independently move to the assisted living facility or sometimes receive home care in their independent living unit. If necessary, they can enter the CCRC’s nursing home or memory care unit. A CCRC is a good option for seniors who want to age in place but might not have the support system to do so.
CCRCs are paid for through private financing unless services are received in a Medicare-certified skilled nursing facility. “The chief benefit of CCRCs is that they provide a wide range of care, services and activities in one place, offering residents a sense of stability and familiarity as their abilities or health conditions change. But that comes at a cost as most communities charge a substantial entry fee” (AARP, 2022). “The average initial payment is about $402,000, but the fees can range widely, from $40,000 to more than $2 million, according to National Investment Center for Seniors Housing & Care, which tracks costs at some 1,100 CCRCs in 99 major U.S. markets” (AARP, 2022). In addition to this entrance fee (which can be nonrefundable should the resident move out or pass away), residents are required to pay a monthly fee based on amenities and the type of contract. If a community isn’t financially stable, there is a risk of losing the entire investment, possibly leaving aging residents financially and medically exposed at the end of their lives.
