What is the Right Type of Post-Acute Care for Your Stroke Patients?

For patients recovering from stroke, it is paramount that they transition to an appropriate post-acute care (PAC) setting for rehabilitation. PAC occurs in facility-based and community-based settings. Most often stroke patients are transitioned to inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), outpatient therapy clinics, or to home with nursing care and therapy from a home health agency.

Selecting the appropriate level of PAC for rehabilitation is critical for achieving optimal outcomes. But, what do patients and their family members know about PAC? How do they make informed decisions that are in their best interests?

Rehabilitation professionals should be on the front lines educating patients and families about the different services provided in each setting.

Who Goes Where?

Patients who receive PAC follow a myriad of trajectories. About 45% of Medicare recipients are discharged home directly from acute care, and 40% of these patients receive no PAC.1 The remaining 55% go to a facility-based PAC setting, where 44% of these patients are discharged to an IRF and 56% are discharged to an SNF.1

IRF & SNF: What the Data Says

According to the Medicare Payment Advisory Commission (MedPAC), rehabilitative stroke care received at an IRF costs more than care at an SNF ($20,864 vs. $15,873). Patients discharged from an IRF also create higher costs in the 30 days post-discharge.2

However, two other studies that looked beyond the initial costs of rehabilitation demonstrated a different picture:

  1. A 2014 study showed stroke patients receiving rehabilitation in an IRF benefited in the following ways when compared to patients received rehabilitation at an SNF:3
    1. Earlier discharge to home
    2. Higher likelihood of remaining at home
    3. Lower mortality rates
    4. Fewer emergency room visits and hospital
  2. A 2015 review of data from more than 69,000 stroke patients had similar results of lower mortality rates and lower readmissions.4

This data suggests we need to consider multiple factors when talking with patients and families about both IRF and SNF options.

What is a Rehab Professional’s Role in Care Transitions?

We must proactively advocate for stroke patients to receive rehabilitation in the most appropriate PAC setting. As rehabilitation professionals, we have a responsibility to:

  • Understand the different levels of PAC, including types and intensity of rehabilitation services provided
  • Understand the admission requirements for each level of PAC
  • Know what levels and types of rehabilitation are available in the local area or region
  • Work with our colleagues in acute care so they also understand the PAC options available
  • Know the potential outcomes for stroke patients based on different levels of PAC
  • Advocate for stroke patients to transition to the right level of care at the right time

When advocating for different PAC settings, keep in mind the following ideas:

  • Acute care case managers and discharge planners are often under pressure to discharge patients to any available PAC bed – whether it be in an IRF or an SNF.
  • Acute care providers may be unaware of the differences in types and levels of PAC.
  • Acute care providers may sometimes assume the level and intensity of rehabilitation services are similar across sites when the word “rehabilitation” appears in the facility name.

Advocate For Your Patients

As rehabilitation professionals, we play a major role in helping stroke patients make the transition to the appropriate setting. If we want them to achieve optimal outcomes, we must be educated and knowledgeable about all PAC options and advocate for our patients to receive appropriate care at the right time.

  1. Bettger, J.P., McCoy, L., Smith, E.E., Fonarow, G.C., Schwamm,. L.H., & Peterson, E.D. (2015). Contemporary trends and predictors of postacute service uses and routine discharge home after stroke. Journal of the American Heart Association, 4(e001038). doi: 10.1161/JAHA.114.001038. Retrieved from: http://jaha.ahajournals.org/content/4/2/e001038
  2. Medicare Payment Advisory Commission (MedPAC) (2012). Report to the Congress. Washington DC: MEDPAC. Retrieved from http://medpac.gov.
  3. DaVanzo, J.E., El-Gamil, A., Li, J.W., Shimer, M., Manalov, N. & Dobson, A. (2014). Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities (IRFs) and After Discharge. A Report submitted to the American Rehabilitation Association Research Institute. Vienna, VA: Dobson DaVanzo & Associates, LLC.
  4. Bettger, J.P., Liang, L., Xian, Y., Peterson, E.D., Bushnell, C., Duncan, P. W., Federspiel, J., Stein, J., Montalvo, C., Lutz, B.J., Hoenig, H. Schwamm, L.H., Wu, J. Stafford, J., & Thomas, L. (2015), Inpatient Rehabilitation Facility Care Reduces the Likelihood of Death and Rehospitalization After Stroke Compared with Skilled Nursing Facility Care (Abstract 146). Stroke, 46, A146.