For years, within acute care hospital walls, levels of care have been partitioned and a patient moved between those levels specific to the needs of the individual. There are emergency departments, critical care units, sub-specialty areas for dialysis, maternity, cardiac care, trauma and the list goes on. You name it and there is most likely a larger care center that can specifically meet those needs based on the program and resources needed in depth for the most effective and efficient care of that population.
This is not so for rehabilitation. In contrast, rehabilitation is a word that is used quite extensively for many venues of care from drug rehabilitation to the housing market! There is a distinct difference for physical rehabilitation and the various levels of care associated with post acute care rehabilitation. Post acute care rehabilitation is predominantly focused on the medical and functional needs of the individual and the level and percent of management between medical and functional seems to hold the key to what determines reasonable and necessary. The resources to maintain vigilance of care and how rapidly the resources can be provided will help accelerate a preferred community discharge.
If regulations presently practiced were placed on hold, long enough to allow medical professionals the time to create the decision tree for moving a patient along the continuum of recovery without barriers and with shared and continued management at the intensity specifically required for the patient; it is likely that inpatient can be represented as a continuum, and not partitioned venues of LTCH, IRF and SNF as it is today.
If this is an immensely scary statement (because you are one of so many companies that now operate as a total definition of one level of the post acute care service line) you should look at the potential rather than challenges you could face. Regulations could incorporate levels – patient access to the RIGHT level of care required by the individual. Can every site now operating as a post acute care single model define service minimum, medium and extensive medical oversight that enables management of all levels within their setting? Can every model have similar characteristics and scoring tools that rely on the same definitions so that the entire episode of care is captured and comparative? Medicare believes so and whether that is done through an accountable care organization (ACO), a continuing care hospital (CCH) or the CARE Tool assessment schematic, the most important factor is that a patient’s recovery is dependent upon internal and external resource ability. Furthermore, every patient has the right to return to the community at the pace most advantageous to them and not respective of a front end matching process that is too prescriptive. Read how one rehab hospital increased revenue by $1000 per patient thanks to a new scoring process.
A patient could enter the post acute setting, be appropriately assessed by clinicians familiar to set post acute plans of care at the right level and then the patient is moved as quickly as tolerated each day. What’s important is keeping the patient engaged all day, appropriate to their required discharge expectations without regard to arbitrary three hour rules, or patterns of intensity now prescribed by skilled. Be ready to do one thing – focus on the barriers as a team with the resources you have available to expedite discharge and appropriately meet the patients able and desired engagement potential. For the sake of the patient add more points of access for every level of post acute rehab.
Single point access to all post acute care venues pushes the outcome as being the defining marker. Reward those that provide the greatest outcomes for comparative resource requirements based on patient acuity. I worked in a facility that had rehab and skilled within the same location (different units), and despite our gut feelings of where a patient might succeed best, we were limited by the regulations that defined conditional process rather than flexibility appropriate to a patients day to day needs.
We should embrace a post acute rehabilitation model of care whose sole focus is meeting barriers to discharge, and measuring success daily toward functional progress in meeting the defined requirements. Post acute rehabilitation should stop wasting time counting prescriptive therapy minutes so that continuous rehabilitative practices by all who touch the patient becomes key in training the success needed to get the patient home. Yes, 24/7 the patient deserves rehabilitative type care and it doesn’t require a level of care label. It means continuous advancement of a patients self re-engagement of their own care as they themselves can absorb it with one goal in mind – HOME. 
