Planning for Inpatient Rehab Services



Family Caregiver Guide


Short-Term Rehab Services in an Inpatient Setting

What Is Rehab?

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:

  1. The goal of rehab is to help patients be independent—to do as much for themselves as they can.
  2. Rehab is done with a patient, not to a patient. Your family member must be willing and able to work with the rehab team during active treatment and, later, with you or other caregivers or by themselves at home.
  3. The patient’s chronic (long-term) health conditions, such as high blood pressure or heart problems, are treated during rehab, but they are not the reason the person is in rehab.
  4. Most rehab services last weeks, not months.
  5. Medicare, Medicaid, and most private insurance plans cover rehab when ordered by a doctor, but there will probably be extra costs. (See page 7 of this guide for more about costs.)

Where are Rehab Services Provided?

Inpatient Rehab Settings

Inpatient rehab can take place in any of these settings:

  • A separate inpatient rehab facility (IRF). These rehab programs are usually very intense. That is why they are often called “acute rehabilitation.” Patients must be able to benefit from, and receive, at least three hours of therapy five days a week. Some patients may be admitted even though they are not able to tolerate an intense program at first if the therapists believe that the person will be able to improve quickly. Talk with your family member about whether this setting is right for his or her needs. Think about current illnesses as well as other chronic health problems.
  • Rehab unit within a Skilled Nursing Facility (SNF)—the formal name for a nursing home. Most patients who are discharged from a hospital to rehab go to a SNF (pronounced like “sniff”). These programs offer the same types of services as an IRF but at a less intense level. That is why they are often called “subacute rehabilitation.”
  • Special settings. Some types of rehab take place in special settings in a hospital, such as brain injury, stroke, or cardiac (heart) units. Ask hospital staff if this is an option for your family member.
Sometimes hospital staff will say things like, “We’re going to send your mother to a nursing home.” Don’t panic. They generally mean a rehab unit in a skilled nursing facility (SNF), not a permanent nursing home placement.

Outpatient Rehab 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.

Making a Choice about Settings

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:

  • Amount of services. Some rehab settings are more intense and active than others. What level of rehab is your family member likely to be able to benefit from?
  • Location. The ideal is a rehab setting near where you live or work. That makes it easier for you to visit. You may want to go to therapy sessions with your family member, learn how to help him or her do exercises, find out whether you need to make changes in the home setting for the return, learn how to prevent injuries to your family member and yourself, help plan for discharge, and offer comfort and moral support throughout the rehab process.
  • Cost. Medicare, Medicaid, and most private health insurance plans may pay all or some of the rehab costs. There are strict guidelines, however, and there may be costs that insurance doesn’t cover. Learn as much as you can from the hospital discharge planner or someone in the financial office of the rehab facility.
If your family member is on Medicare and is being treated in a hospital, make sure that he or she is actually an inpatient. You may have to check with the financial office to find out since patients under observation are treated just like admitted patients.
  • Hospital admission status. To be eligible for Medicare coverage in a SNF, your family member has to have been in the hospital for three days, not counting the day of discharge. Another important exception: Medicare doesn’t count being “under observation” as part of the three-day requirement. Observation status occurs when a patient comes to the Emergency Department and the doctors feel that the person isn’t sick enough to be admitted as an inpatient, but they aren’t sure whether the patient is well enough to go home. The patient may be sent to a regular floor even if they are not admitted but considered under observation. In this case the hospital bill for the patient may be higher than if he or she were actually admitted.

Rehab Services

  • Physical therapy (PT). This helps patients who have problems in moving, balance, walking, and performing other physical activities. PT can also help patients learn to use prosthetic (artificial) arms or legs, shoe inserts, wheelchairs, walkers, or other assistive devices.
  • Occupational therapy (OT). This helps patients be more independent with self-care and other daily tasks, such as eating, getting dressed, typing, and using the telephone.
  • Speech therapy. This helps patients who have suffered strokes, brain injuries, or other conditions relearn language skills, such as talking, understanding spoken and written words, and dealing with memory problems. It can also help with swallowing problems.
  • Psychological counseling (or simply “counseling”). This helps patients (and sometimes also their family members) adjust to major life changes caused by an injury or illness. Counseling may be offered to one person at a time or in a group.

Going from Hospital to Inpatient Rehab

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:

  • Transfer of information. Hospital staff should tell the rehab staff what treatments your family member received, what medications have been prescribed, and any other factors that affect continuing care. Ask the discharge planner or case manager at the hospital to make sure this information has been sent, and ask the case manager at the rehab facility if it has been received. If the transfer is taking place at the end of the day or before a weekend, make sure that necessary medications for the next day or two are sent with your family member. Not all rehab facilities have well-stocked pharmacies.
  • Clothing. Your family member will need loose, comfortable, everyday clothes and sturdy shoes to participate in PT or OT sessions. The facility does not provide these items, so you will have to bring them from home or buy them. It is important to put labels in the clothing and bring them to the facility on the day of admission. Ask the rehab team if there are any special requirements for clothing.
  • Initial assessment. Rehab staff will assess your family member in the first day or two after admission. They want to be sure that your family member needs a skilled level of service, either for improvement or for maintenance (preventing further loss of strength, skills, or mobility). Insurance pays for rehab services only if they must be provided by a skilled professional.
  • Rehab begins. The amount of time your family member spends in rehab depends on his or her tolerance level and the type of setting. Staff will assess your family member throughout the rehab process to determine ongoing needs.
If rehospitalization is necessary, ask about the rehab facility’s “bed hold” policy—the amount of time it will hold your family member’s place at the facility and the financial responsibility that may entail.
  • Care plan (“team”) meeting. After rehab has started, this meeting takes place regularly. It includes staff from nursing, social work, dietary, recreation, and rehabilitation departments. They will discuss your family member’s treatment and any problems. You and your family member should ask to attend. This is a good time to ask questions and raise any concerns.

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

Factors That Affect a Patient’s Rehab Progress

  • Patient motivation. Not everyone approaches rehab in the same way. Motivation can depend on a person’s illness, type of rehab, tolerance for pain or stress, and other factors. Some people like the challenge of rehab, while others do better without pressure. Sometimes it is hard to know whether to respond with a gentle or a firm approach. Praise, even for small advances, is always good. You can help by talking with rehab staff about how your family member has dealt with other life challenges.
  • Relationships with therapists. Your family member will likely work with many therapists, each of whom has a different style. Let each therapist know what works best with your family member, and ask that this information be written in the treatment plan.
  • Expectations. One of the hardest parts of rehab is being realistic about how much function a patient can get back. Some patients make a full recovery and go home even more mobile than before (for example, a patient who has had a hip or knee replacement). Others improve just a little or need continuing therapy to maintain the highest level they can achieve. Maintaining function and preventing further decline can be as important as improvement.
  • Feelings. Rehab is not just about workouts. It’s an emotional experience as well. There may be feelings about the injury or illness, difficulty in accepting limitations, or frustration related to overly optimistic expectations. Feeling tired, angry, discouraged, and overwhelmed are all common feelings in rehab. Talk with the staff if you feel that your family member’s emotional state may affect the rehab process. As a family caregiver watching or being part of the process, you will also have many strong feelings. You may need to talk with someone in or outside the facility as well.
Here are some ways to help. Develop a good relationship with the rehab staff, including the night staff, especially if that’s when you visit. Encourage your family member to be as independent as possible. Ask your family member whether he or she wants to have you attend some therapy sessions or not. Use some time in your visits just to talk and share family news. There’s life beyond rehab.

Paying for Rehab Services

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:

  • Need skilled nursing care 7 days a week or skilled rehab services 5 days a week. A doctor or nurse practitioner must certify that your family member needs these services.
  • Have been admitted to a hospital for at least 3 consecutive days (not counting the discharge day or observation status) within the 30-day period before going to a SNF.
  • Be admitted to the SNF for the same illness or injury that was the reason for the hospital stay.
  • Be assessed by rehab staff at least once a week.
  • Be within a defined “benefit period.” A benefit period begins on the first day your family member is admitted to a hospital or SNF and continues for up to 100 days. It ends when your family member has not received services from a hospital or SNF for 60 days in a row. If your family member goes into a hospital or a SNF after one benefit period has ended, a new benefit period begins. He or she must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

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.

More information on the Jimmo case and CMS statements is available on the Center for Medicare Advocacy website. Some tips for advocacy: Print out the information on the Jimmo ruling and the CMS statement and bring them with you to any discussion about continued rehab services. Take careful notes about what you are told, by whom and when. Be confident, clear, and polite.

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.

Other Costs

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:

  • Private telephones, haircuts, and other personal care services.
  • Special clothing for therapy sessions.
  • Transportation. While Medicare or other insurance may pay for an ambulance to take your family member from the hospital to a SNF or other inpatient facility, it may not pay for the costs of going elsewhere for other tests in an ambulance, ambulette, or other transportation service.

Planning for Discharge

It’s never too early in a rehab stay to start thinking about discharge. Patients may be discharged to:

  • Home, with no needed services.
  • Home, with help from a family caregiver
  • Home, with help from a home care agency, including skilled care from a PT or other therapist.
  • A long-term care setting (such as a nursing home or assisted living facility)

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.

Appealing a Discharge Decision

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.

When Discharge Home is Not Possible

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.

Choosing and paying for hospital beds, wheelchairs, and other durable medical equipment, when needed, can be complicated. The Next Step in Care Guide on durable medical equipment can help you get started.

Going Home from Rehab

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:

  • Home health care services. Your family member may be eligible for continued therapy at home or at an outpatient clinic. You can learn more about home health care services in the Next Step in Care guide “Home Care: A Family Caregiver’s Guide.”
  • Medication management. Your family member’s medications were probably changed—more than once—while he or she was in the hospital and in rehab. Make sure you understand exactly why new medications have been added and what old medications should be continued or stopped. See the Next Step in Care guide on Medication Management and the Medication Management form.
  • Primary doctor follow-up. Just as you would do following a hospital discharge to home, you should arrange a visit with your family member’s primary doctor as soon as possible. There’s a lot of information to cover so be prepared with a good summary and an up-to-date medication list. It’s important to get an appointment as quickly as possible; see the Next Step in Care guide “Getting a Post-Discharge appointment in 7 Days” for some tips.
  • Financial accounting. Make sure to review all the rehab bills carefully, and make sure that your family member received all the listed services. Let the rehab facility or insurance company know if there are questions. This is a job that you might ask another family member to take on.
  • Care coordination. All these responsibilities and other tasks may seem overwhelming. You can get help from care managers (sometimes called case managers, navigators, or other terms) from the rehab facility, health plan, or a community organization. The Next Step in Care guide on care coordination will help you manage this aspect of care at home.

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.