The Foglight - Leaving the Hospital, Part 2: Levels of Care

December 2023

Issue # 6 December 2023
In This Issue: Hospital Discharges, Part 2

Dear Reader,

The transition from hospital to home can be tricky. The American insurance system incents hospitals to tightly manage the time a patient stays in the hospital. Discharges can feel, and sometimes are, abrupt. The choice of where the patient will go next is not an easy one to make. Having a good understanding of the pros and cons of each type of option helps the patient and their loved one feel more confident.

Many people leave the hospital and go to a rehabilitation facility. It can be an intimidating situation, especially when you have to quickly choose the next place. Before you pick the place, be sure you understand the differences between the types (levels) of facilities. Please read on for part two about levels of care issues, with some real examples.

Leaving the Hospital, Part 2: Levels of Care

In some ways, the discharge of a patient from the hospital can be as stressful—even more so—than the admission to the hospital. Ideally, being admitted to the hospital marks the entry of a patient into a world of caring professionals; and as long as the patient is in the hospital, the family members breathe a little sigh of relief. Whatever failings the hospital may have, the patient has better access to care than he or she did the moment before being admitted. Being discharged has the opposite effect: it’s the release of the patient from a cocoon of professional services back into the great unknown. It’s a scary time.

Last month, I promised to discuss steps you can take, as a family member or friend, without the doctors or hospital, to make the patient’s discharge smoother and safer. To begin, you need to understand the options available for where the patient should go—because there are many possibilities. And to find the right place, the first thing you need to do is understand the various levels of care.  Your loved one may need to go to an in-patient rehabilitation facility … or a sub-acute rehab facility….or a long-term acute care hospital (LTACH) … or back to their home, with or without a wide variety of supports (only some of which insurance will cover).

Inpatient rehabilitation is also known as acute rehabilitation. This is an intense level of care with stays that are 3- 6 weeks long.  The doctors, nurses, and therapists have special expertise in recovery after illness or injury. The catch is that the patient must need, benefit from, and tolerate 3 hours or more of therapy (Physical, Occupational, or Speech) per DAY. Many people don’t qualify.

Subacute rehabilitation is known as nursing home rehabilitation. This is a less intense level of care with stays from weeks to months. There is less expertise in recovery and more expertise in caring for older people. The length of stay varies widely, and in my experience is driven as much or more by the insurance source than the medical condition. The frequency of physician visits and staffing can also vary widely from one subacute to another.

Long-term acute care hospital  (LTACH) is a care level designed for very ill people, often on ventilators or dialysis. The stay is usually about 1 month, followed by a step down to a subacute unit. There are daily physician visits and some rehabilitation. People usually step down after an LTACH stay to subacute.

Home is where we all want to be. To go home, the patient must be safe. To be safe, the person must be able to care for themselves (or have others with them that will provide care). When thinking about home consider the person’s ability to toilet, wash, and dress, prepare meals, do light housework such as laundry and dishes, and manage their medications. Keep in mind that insurance typically pays for a few hours a week of care, and therapists will likely start days or even a week or two after discharge.

The hospital will make a discharge level of care recommendation based on input from the doctor, physical therapist, plus ideally you and your loved one. Sometimes there are several options regarding which level of care might fit best for your loved one. Make sure you understand why the hospital suggested the specific care level and what the other options might be.

A woman had paralysis from a spinal cord injury and wanted to wean from her ventilator. She initially went to inpatient rehabilitation, then to subacute, and then after a re-hospitalization, to LTACH.  But by then she had developed serious complications from the tracheostomy tube. The family will always wonder if she should have gone to LTACH first. While we don’t know the answer, they resented that the hospital never discussed the option.

A man had a serious injury after falling off a ladder and went to inpatient rehabilitation. During the stay, he developed an infection and the family supported re-hospitalization. The family was expecting him to return to inpatient rehabilitation since he had only been there a few weeks. Unfortunately, the inpatient rehabilitation wouldn’t take him back and he had to go to subacute from the hospital. The family was unhappy with the expertise at the subacute and wished they had never agreed to let him leave the inpatient rehab.  

A woman had a poor outcome after heart surgery and went to an LTACH to wean her from her ventilator. The family was unhappy with the rehabilitation services at the LTACH and after she was re-hospitalized for a procedure, we chose a different LTACH with better rehabilitation support rather than subacute. With coaching from me on what to expect and how to ask for it, she improved.

Once you have determined the right level of care for your loved one, the job is not over. In fact, now is when the job really begins, because next you must pick a specific place. And that crucial decision is what I'll cover in my next article.

My warm wishes for a peaceful and healthy holiday season and new year. 
- Dr. Gerda Maissel
 

Dr. Gerda Maissel, MD CPE, BCPA

Dr. Maissel is a Board-Certified Physical Medicine
and Rehabilitation physician
and a Board Certified Patient Advocate
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