If your family member is in the hospital for an acute illness, surgery, or an injury, you may be told that the next step in care is “rehab,” short for rehabilitation services. Rehab includes treatment to help patients get back all or some of the movement and function they lost because of the current health problem or treatment. For example, many people who have had hip or knee replacements need exercises and coaching to be able to walk again.
While your family member may still be feeling the effects of hospitalization and need medical attention, he or she will be expected to work hard during the rehab process. You will see many active patients in the halls and treatment rooms. In general, you may find rehab a positive “workout” atmosphere rather than a place for very sick people.
Many patients and family caregivers say that going from hospital to rehab can be confusing. This guide will give you some basic information about what to expect.
Here are five important points to remember:
Inpatient rehab can take place in any of these settings:
If your family member is well enough to be at home, rehab provided by a home health care agency as a “skilled service” may be an option. Another option may be rehab at an outpatient clinic, or in a doctor’s or physical therapist’s office, but your family member must be able to travel back and forth to that facility.
Unlike hospitals, which admit patients in various stages of illness, rehab settings admit only patients who they think can benefit from the level and kinds of services they provide. So, even if your family member would like to have rehab provided in a well-known IRF, that IRF may not be willing to accept him or her.
Here are some things to think about when making a choice about rehab settings:
Be prepared for a quick move from hospital to rehab. A discharge planner in the hospital (usually a nurse or social worker) will provide a list of rehab settings appropriate for your family member. You and your family member will probably be asked to choose a number of places where you are willing to go. When there is an open bed at any of these settings and your family member is well enough to leave the hospital, you will be asked to accept this placement and leave the hospital. You will not have much time to make a decision—another reason you should be prepared.
Here are some of the things you should expect and watch for as your family member transfers from the original hospital stay to inpatient rehab services:
During the rehab stay, your family member’s medical condition may change, and you or the rehab team may feel that it is necessary to go back to the hospital. It is often better to avoid this if possible. Try to get as much information as you can about what tests or treatments the rehab facility is able to provide before making a decision.
Factors That Affect a Patient’s Rehab Progress
Insurance coverage can be confusing. Whether your family member has Medicare, Medicaid, private health insurance, or some combination of these plans, make sure you find out what insurance will and will not pay for. Talk with someone in the financial office at the rehab facility as soon as you can.
Here are some basic facts about paying for rehab:
Medicare. Medicare has specific rules about paying for rehab services provided by a SNF or home health care agency. To qualify, your family member must:
If the patient meets all these requirements, Medicare pays the full cost for the first 20 days and part of the cost for the next 80 days. Your family member (or someone else) will have to pay a co-insurance fee during these 80 days. The fee is set by Medicare and not by the rehab facility.
Clarification of Medicare policy regarding “continued improvement:”
Until a federal court ruling in January 2013 in the case of Jimmo v. Sebelius, some health care providers incorrectly told patients and families that Medicare would not pay for rehab unless the patient showed continued improvement. Sometimes this was called “restorative potential,” meaning that the patient had to be considered able to be restored to full health and function. The federal Centers for Medicare and Medicaid Services (CMS) responded that this was never agency policy and affirmed its position that it will pay for continued rehab services in a SNF or outpatient setting or by a home health care agency if the patient’s functional abilities would deteriorate without these services. This is often called “maintenance therapy.” There is, however, a financial cap (limit) on these services. When that limit is reached, you can apply for an exception based on the patient’s continuing need. Some exceptions are automatic; others need to be documented. Since many providers may still be unaware of this ruling, you may have to be a strong advocate to get continued therapy for your family member.
Medicaid. Medicaid plans differ by state. Medicaid will pay for rehab if your family member meets the guidelines of the rehab facility’s state about the type and amount of service needed. If your family member is eligible for Medicaid (again, according to state requirements), staff at the rehab facility can help you apply.
Private health insurance. Most health insurance plans follow the same guidelines as Medicare, but many require more frequent assessments assigned to your family member’s care on admission and throughout the rehab stay.
Even when Medicare or other insurance pays for all or most of rehab, there still may be costs that your family member or you have to pay, including:
It’s never too early in a rehab stay to start thinking about discharge. Patients may be discharged to:
Your family member should not leave the rehab facility until there is a safe and adequate discharge plan. This means a plan that meets your family member’s needs and includes consideration of what you can do and what other sources of help might be available. Your family member’s residence (whether it’s his or her own home or your home) may need some adaptations to make it accessible. Part of the discharge plan may involve adding a hospital bed, wheelchair, walker, or other equipment to the home. These are called Durable Medical Equipment (or DME). Choosing and paying for DME can be complicated, and making a workable plan takes time, so that’s another reason to start thinking ahead.
Sometimes the rehab staff comes up with a discharge plan that you do not agree with or feel is safe. You have the right to appeal (ask for another review of) this decision. By law, the rehab program must let you know how to appeal and explain what will happen. Make sure the rehab program provides you with contact information for the Beneficiary and Family-Centered Care Quality Improvement Organization that reviews these appeals in your area.
Appeals often take only a day or two. If the appeal is denied, then insurance will not pay for those additional days your family member has been in rehab. Also, your family member will have to leave the facility immediately.
Although your goal may be to have your family member discharged to home, this is not always possible for a variety of reasons. Some patients move to the regular long-term care part of a SNF or to another long-term care setting because they require more assistance than is possible to provide at home. You should be aware of this possibility. This kind of transition requires planning and careful consideration of your family member’s needs and your own situation. Talk to a social worker at the rehab facility or another counselor about your questions and concerns.
The Next Step in Care family caregiver guide “When Short-Term Rehab Turns into a Long-Term Stay” covers this transition in more detail.
Even if you have done a lot of planning and your family member has done well in rehab, going home is almost always still a big change. As part of the planning, think about all the new responsibilities you will have and learn as much as you can ahead of time. You will want to consider:
Rehab is an important step in helping your family member achieve the most independence and highest function possible. Remember that you are an important part of the rehab team. Use this time well to learn and practice. Both you and your family member will benefit from this step in care.