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The Nuts & Bolts of the Post-Hospital Stay Alphabet Soup: SNF/ALF/CCRC/LTACH/HHA/LTC...what does it all mean?!?!

Hello again! Hope all is well. Today, I'm writing about an issue that faces many older adults and their care partners- one that can be confusing & overwhelming....DISPOSITION OPTIONS.

To manage an acute (sudden/new) illness, many older adults need to spend some time in a hospital. See my prior blog about hospital care tips to help navigate this challenging experience.

Today, I'll concentrate on trying to explain some terms and issues that come up during discharge planning and transitioning out of the hospital hoping that you & your loved ones will be better able to communicate with the hospital teams and others when deciding on the options. I've also attached a Discharge Checklist (at the end of this blog) that you can have on hand to plan as you or a loved one goes through a hospitalization.

Let's start from the very beginning (a very good place to start...). Patient X gets admitted to the hospital. The first thing to find out the admission status: INPATIENT or OBSERVATION. The reason being that with traditional Medicare, a patient needs to be in hospital for 3 MIDNIGHTS to qualify for care in a skilled nursing facility for rehabilitation or nursing care in a nursing home. Observation status is treated as an outpatient and won't qualify for these stays.

As the hospital stay winds down, there could be several options for care afterwards:

  1. Go home

    1. Without any services & resume your prior routine care and follow-up.

    2. With skilled services- nursing and/or rehabilitative.

    3. Engage the care of a home health agency or private home health aide (HHA) to support personal care at home.

  2. Transfer to a Skilled Nursing Facility (SNF, nursing home) for rehabilitation/nursing care.

  3. Transition to a SNF for long-term care (LTC/residential).

  4. Transfer to an Acute Inpatient Rehabilitation Hospital or Unit.

  5. Transfer to an Assisted Living Facility (ALF)

  6. Transfer to a Long-Term Acute Care Hospital (LTACH)

Before we go into a description of the different options, let's get some of the alphabet soup abbreviations defined:


  1. LTC: long-term care. This basically means care that is needed by the patient for an indefinite period of time to support his/her daily living. It is not considered rehabilitative care, but again, care to basically support daily existence (e.g. bathing, dressing, grooming, toileting, feeding, mobilizing & some nursing care- wounds, complex chronic conditions, chronic tubes/drains/catheters, etc.). This care is usually NOT covered by Medicare. It is usually covered by Medicaid & some long-term care insurance plans. LTC usually takes place in a facility (SNF, ALF, CCRC) or at home.

  2. Custodial (Personal) Care. Bathing, dressing/undressing, grooming, toileting, mobilizing, meal preparation (feeding if needed), medication reminders, errands/transportation, shopping,. Usually NOT covered by Medicare (unless during a period when a skilled service is active- see below; or during a rehabilitative stay in a SNF). May be covered by long-term care insurance plans & also by Medicaid; however, most of the time, patients/families have to pay for this privately.

  3. Subacute Rehabilitation: rehabilitation (physical/occupational/speech therapy) that occurs in a SNF. Usually limited to 1-1.5h/day depending on patient tolerance & needs. Part of the post-hospital SNF benefits while skilled care is needed.

  4. Acute Inpatient Rehabilitation: a more intense location of rehabilitative services, usually for specific conditions (e.g. stroke, fractures, trauma, specific neurologic conditions). This is sometimes part of the hospital or located in a separate building/facility. To qualify for this a patient needs a qualifying medical/surgical diagnosis in addition to the ability to tolerate 3 HOURS of therapy per day, 5 days per week. This will need input from the medical & therapy teams in the hospital & is naturally a more selective option because of the intensity of services.

  5. SNF: skilled nursing facility. Usually a nursing home. Most nursing homes have designated & separate sections for long-term care (LTC) residents as well as subacute rehabilitation patients.

  6. ALF: assisted living facility. An independent facility that offers apartment-like residences with additional support. This often includes on-site nursing to help with things like medication administration/management and certified aides to help with custodial care. Often includes meal plans, cleaning services, laundry, activities. For the most part, ALF care & residence IS NOT COVERED BY ANY INSURANCE, INCLUDING MEDICARE. Some facilities, depending on the state, can accept Medicaid when/if a patient has gone through their assets paying privately and meets the eligibility criteria.

  7. CCRC: continuing care retirement community. These are residential developments for older adults where you can find independent living, assisted living, & skilled nursing all on one campus. Depending on the entry buy-in plans, a person's care can be covered in all three facilities if/when needed under one pricing plan or an adjustable plan that increases/decreases depending on the level of care needed. They often have a health or medical center on site staffed by nurses and providers- the models of care vary & do not have a standard. Do your research before considering this as an option as there are many nuances to understand before transitioning here. This may not be an option for a direct transfer after a hospital stay (unless you use their SNF for rehabilitation), but is an option to keep in mind.

  8. LTACH: long-term acute care hospital. This is a facility or unit meant for long-term acute care. Basically- if a patient will need HOSPITAL level of care for an extended period of time (usually > 25 days), the option to transfer to an LTACH may be appropriate. These facilities/units provide all the care you see in a "regular" hospital, but are prepared to manage the patient for a long-stay. They have become more popular because most of the hospitals we are familiar with are increasingly focused on short-stays- that is, admit, solve/fix the immediate problem, & discharge to the next place of care. So, if you are going to need acute hospital level of care for a prolonged period of time, they may not be the ideal option. LTACHs are equipped with all the radiologic, surgical, & medical services and providers that a "regular" hospital has. They may be appropriate when/if a patient may need things like long-term ventilator management, tracheostomies, feeding tubes, high level wound care, etc. An LTACH stay is covered by Medicare (considered an acute hospital stay). Most Medicare Advantage (Managed Medicare) plans will cover the stay as well, but have pre-authorization requirements & reviews.

  9. HHA: home health aide or agency. An aide is an individual trained in providing personal care to an older adult or patient. S/he can help with things like bathing, dressing, grooming, toileting, feeding, & mobilizing. They can also potentially help with light chores/housekeeping, errands, meal preparations, transportation, etc. For the most part, they are paid for privately- meaning out of your own funds. Some long-term care insurance plans cover some of the care and it's important to find out how much & what your plan covers if you have one. Medicare will cover HHA services only for the duration a skilled need is in place; once that skilled need ends, so does the coverage. Aides can be engaged through an agency or privately. Agency based aides receive specialized & focused training and may also be certified. Usually, an agency will require a minimum amount of hours per week and it is helpful to find out the cost for the different hours- e.g. daytime, evening/overnight, weekends/holidays as they may vary. Some agencies can also provide live-in (24/7) aide care; in this situation, it is important to find out how the aides' hours are structured so that they are also allowed their time for sleep/rest & personal needs. Agency aides may also be limited in their roles- for example, they cannot do any kind of care outside of their scope of practice. So, if a patient scrapes their arm & needs some simple wound care, the aide might not be able to provide this- it would have to be done by a family member or nurse. Also these aides can remind a patient to take medications, but cannot administer the medication to the patient. The advantage of agency based aides though is that you tend to have a reliable schedule with plans for back up & accountability in place. If you hire an aide privately outside an agency, you might have more flexibility in what the aide can/cannot do. However, you will have to be prepared with back-up plans if/when the aide is not available or calls out. And, of course, finding an aide privately can be a challenging task- you may have to rely on friends, family, or other local contacts; kind of like word-of-mouth in finding private childcare.

  10. "Skilled services" Basically- they are issues that need the attention of a nurse and/or therapist (physical, occupational, speech) during the recovery period. Skilled nursing services can include things like wound care, intravenous medication management, close monitoring of complex chronic conditions (like CHF, diabetes), managing tube feedings and other things like catheters/drains, or ostomy care. Skilled therapy services include interventions to restore function so that the patient can manage at home safely- transferring, ambulating, assessing for devices that may improve functioning. Skilled services DO NOT INCLUDE what we consider basic personal care- bathing, dressing/undressing, grooming, toileting, meal preparation, transportation, running errands, getting groceries, filling prescriptions, etc. These are considered CUSTODIAL CARE services.

Now, if a patient has had an INPATIENT admission for an acute illness, stayed the 3 midnights, and is felt to need skilled nursing or therapeutic services, the team can work with the patient & family to determine if these skilled services should occur in a SNF or at home.

The SNF Post-Hospital Care Option:

This can be appropriate if the conditions are complex and need a higher level of monitoring and follow-up and help at home is limited. Under traditional Medicare, each beneficiary has 100 skilled days covered per calendar year. With this benefit, a patient can transfer to a SNF for a period of time to recover- the goal being, ultimately to return home or to another option for long-term care (LTC). A patient using this benefit should be able to tolerate 1-1.5 hours of therapy per day, usually for 5-6 days per week; this is a combination of physical/occupational/speech therapy. While receiving services in a SNF for rehabilitative care after an acute illness, a patient's custodial care is also covered- this is the only situation in which Medicare covers these services.

However, there are a couple of things to remember. A patient's progress & status are monitored continuously by the nursing home team. If/when a patient reaches his/her goals or "plateaus" (stops making progress or is unable to make progress), his/her skilled nursing need ends. At this point, the SNF is no longer felt to be appropriate & decisions need to be made for further care/transitions. Also, care in the SNF is covered fully for the first 20 days. Starting on day 21 & through day 100, there is a percentage of the daily fee that needs to be paid by the patient/family (usually $200-300, depending on geographic location/state). The rest of the percentage is paid for by Medicare. After day 100, care is no longer covered by Medicare & a patient/family will need to either pay privately or consider other options for LTC- a complex process.

CAVEAT- the above information pertains to traditional Medicare only. Managed Medicare (Medicare Advantage) is a whole different ballpark. This process usually requires pre-authorizations and approvals for a certain amount of days at at time with the need to continuously revisit, obtain continued authorization, etc.

The HOME Post-Hospital Care Option(s):

If a patient does pretty well and has been able to maintain his/her function after the acute illness, s/he can possibly return home without any services- basically, back to the level of care prior to the admission.

Alternatively, if there has been a new decline in function/strength and or a new skilled nursing need, s/he may be advised to go home with skilled home care services. These are also covered by Medicare & include nursing & therapy as per the medical & hospital team's recommendations. In this situation, a nurse usually will come out to see the patient weekly with the frequency adjusted depending on the condition. The therapists will come out to see the patient at home 2-3x/wk for about 1 hour sessions. The goals will be to try & get the patient to a level where s/he can manage safely at home. An aide might also be available- if the home nursing/therapy teams feel it necessary. The aide can help with things like bathing/dressing/undressing and is usually covered for about 1 hour/day, maybe 2 or 3 days per week. These services can remain in place and be covered by Medicare as long as the skilled need is active. Once this need is resolved/improved, that's it. Therapy would likely transition to outpatient therapy (usually at an outpatient center, sometimes in the home) and nursing/aide services usually end.

Whether or not a patient needs skilled services, if s/he or the care partners need additional support for custodial care, they may need to engage a privately paid aide/companion through a licensed/certified home health agency (HHA) or other means. Medicare & most insurances do NOT cover this care; however, some long-term care insurance plans do & it is worth checking with them regarding the details as it can be variable.

Once the acute recovery period ends and/or the skilled needs resolve, plans will have to be in place for LTC options. These can include staying at home with additional supports if needed (usually hiring an aide/companion or family/care partners if they are available); transferring to LTC in the SNF/nursing home; transferring to LTC in an ALF; or considering a residential option like a CCRC. All of these decisions will have to balance a patient's needs- medically, functionally, & emotionally along with his/her resources, insurances/coverage, & of course- most importantly- preferences for care.

So, the bottom line- discharge planning can be overwhelming, but start by getting to know the terms, insurance coverage, options, & definitions It's a complicated maze and needs research. A geriatrician can often help with this as s/he usually has practiced in all these venues of care and is familiar with the level of care provided. S/he can also medically & functionally assess a patient to determine which venue is optimal for the patient. And, in working with a discharge planner or care manager, a comprehensive plan can be put into place to support the immediate and long-term needs of an older patient after a hospital stay or acute illness.

As with anything in geriatrics- it's complicated, but with the right care team in place, a clear path to better health & function can be navigated smoothly.

GPS.Discharge Planning Checklist
Download PDF • 75KB

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