Admission Criteria for Facility-Based Post-Acute Services

Admissions to post-acute care facilities are growing as a result of the effort to decrease length of hospital stays and to reduce hospital readmissions. Rather than discharging patients directly home, hospitals are commonly transferring patients to post-acute facilities. One reason for this trend is that the transfer to an inpatient facility for post-acute services can occur more quickly than a direct discharge home—resulting in less time spent in the hospital. Another reason is that the greater oversight provided by professional caregivers in a post-acute facility decreases the likelihood of hospital readmission. To prevent the inappropriate use and potential overuse of these services, however, Medicare and other payers have rules to ensure that transfers to post-acute facilities are appropriate. Still, much of the criteria are vague and subjective.

Foremost, a healthcare provider must determine that care services are medically necessary and cannot be safely provided in the home setting. Once it is established that the patient cannot safely be discharged to their own home, the healthcare provider should consider alternative settings (Table 1), beginning with the least expensive setting, a nursing home–based subacute unit; then an acute inpatient rehabilitation setting; and, finally, the most restrictive post-acute setting, a long-term acute care hospital (LTACH). In addition to these three types of post-acute care facilities, other settings, such as custodial care rendered in a skilled nursing facility (SNF) or an assisted living community, may be warranted when care at home is not possible.

All stakeholders involved in the post-acute world need to be well versed in the entry criteria for each of these facilities.

Subacute Care Facility

Subacute care is a distinct form of health care service that focuses on providing the skilled medical care needed to transition the patient to the home setting after a qualifying acute-care hospitalization. Although the qualifying hospitalization typically must be a minimum of 3 days long, Medicare and managed care plans are increasingly granting waivers to this requirement in an effort to decrease the hospital length of stay.

Inpatient subacute care may be used specifically for rehabilitation purposes for any number of conditions. In general, the rehabilitation needs of patients in these settings include fewer than three treatment modalities and most often physical therapy. Beyond the need for physical therapy, patients can also qualify for subacute services under one of the following: observation, assessment, and monitoring of a complicated or unstable condition; complex teaching services to the individual or caregiver requiring 24-hour SNF setting versus intermittent home health care setting; complex medication regimen; initiation of tube feedings; active weaning of ventilator dependent individuals; or wound care (including decubitus/pressure ulcers).

Although Medicare Part A benefit covers up to 100 days of subacute services, most stays in subacute care facilities are much shorter than that, lasting 27 days on average. There must be daily documentation of the patient’s progress or complications in order to maintain coverage of subacute care.

Acute Inpatient Rehabilitation Services

Inpatient rehabilitation services are often thought of as being a step above subacute care. Postoperative acute inpatient rehabilitation at an inpatient rehabilitation facility (IRF) may be considered medically necessary for individuals undergoing more than one major joint replacement during a single hospitalization, but Medicare and other payers typically do not consider it to be medically necessary when a single joint is replaced. Exceptions are made when the individual has a serious comorbidity or comorbidities that result in functional deficits that necessitate an acute inpatient level of rehabilitation in order to achieve a satisfactory outcome within a reasonable time period.1

Hip and knee replacements, also known as lower extremity joint replacements (LEJRs), are some of the most common surgeries that Medicare beneficiaries receive. In 2013, there were more than 400,000 Medicare claims for inpatient primary procedures, costing more than $7 billion for hospitalization alone.2 In an effort to control these costs, the Centers for Medicare and Medicaid Services (CMS) implemented the Comprehensive Care for Joint Replacement Model.2 Within the model, a bundled payment is provided on the basis of a quality measurement for the complete episode of care associated with a hip or knee replacement. The Comprehensive Care for Joint Replacement Model aims to hold hospitals, physicians, and post-acute care providers financially accountable for the quality and value of the care they deliver to Medicare beneficiaries for hip and knee replacements, from surgery through recovery. Additionally, the episode of care structure encourages health care providers to increase their coordination of care.

Acute inpatient rehabilitation services are available for patients requiring acute rehabilitation, defined as restoration of a disabled person to self-sufficiency or maximal possible functional independence.3 To qualify for an IRF, patients need to utilize an interdisciplinary, coordinated team approach that involves a minimum of 3 hours of rehabilitation services daily. Continuation of acute rehabilitation services at an IRF requires evidence of progress toward stated goals, documented by objective functional measurements.4 In addition to hospital conditions of participation for Medicare and Medicaid patients admitted to IRFs, CMS operates under the “60 Percent Rule”,5 meaning that a designated percentage of admissions must fall within specific diagnostic categories to maintain IRF accreditation.

Long-Term Acute Care Hospital (LTACH)

Care provided by an LTACH is hospital-based care, and, as such, admission requires documentation that patients have a complicated course of recovery that requires prolonged hospitalization. Treatment at an LTACH may be required in the face of complex medical issues that meet the criteria of two or more medically active conditions that require: three or more interventions including intravenous medications, continuous intravenous fluids (but not a “keep vein open” order), total parenteral nutrition or peripheral parenteral nutrition, and blood products; at least one physician visit per day; frequent diagnostic services; and active participation in therapies at least 5 days per week. Beyond general complex medical issues, the other two major categories that may require LTACH level of care include complex wound/burns and mechanical ventilation weaning.

Skilled Nursing Facility (SNF)

For patients who are unable to be cared for in their own home, placement in an SNF may be needed for custodial care. The definition of SNF eligibility is increasingly critical, as this criteria applies to admission not only to an SNF, but also to an Assisted Living Community (ALC), via Medicaid waiver programs, as well as the PACE (Program for All-inclusive Care of the Elderly) program.

Custodial care is care that is primarily for the purpose of assisting the individual in meeting personal rather than medical needs, which is not specific therapy for an illness or injury and is not skilled care. Also custodial care serves to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, preparation of special diets, and supervision of medication that usually can be self-administered. Custodial care is maintenance care provided by health aides when an individual has reached the maximum level of physical or mental function. In determining whether an individual is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished rather than the diagnosis, type of condition, degree of functional limitation, or rehabilitation potential.

The Long Road Home

The transition from the hospital to the home is not an easy one, as it requires careful reconciliation and management of medications, a primary care physician follow-up, and the provision of education to patients regarding the successful management of their condition. It is for all of these reasons that post-acute facilities are often incorporated into such transitions. But getting patients home safely and in an efficient and effective manner requires the appropriate use and management of these post-acute settings. Knowing the admissions and eligibility requirements and developing processes to ensure appropriate management are critical for best serving our patients. 

1.    Centers for Medicare and Medicaid Services. Inpatient Rehabilitation Therapy Services: Complying with Documentation Requirements. Medicare Learning Network. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Inpatient_Rehab_Fact_Sheet_ICN905643.pdf. Published July 2012. Accessed October 28, 2015.

2.    Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement Model. http://innovation.cms.gov/initiatives/ccjr/. Updated October 22, 2015. Accessed October 26, 2015.

3.    Anthem. Clinical UM Guideline: Acute Inpatient Rehabilitation. https://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051177.htm. Effective October 6, 2015. Accessed October 28, 2015.

4.    Tenet Health. Regulatory Compliance Policy: Inpatient Rehabilitation Facility Admission, Continued Stay, and Discharge Criteria. tenethealth.com/docs/default-source/policies/policies---mn/policy---comp-rcc_4-11_inpatient_rehabilitation_facility_admission_continued_stay_and_discharge_criteriab51601874311628fa2cdff000017c386.pdf?sfvrsn=2. Effective May 29, 2013. Accessed October 28, 2015.

5.    Centers for Medicare and Medicaid Services. IRF Classification Criteria. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Criteria.html. Updated August 24, 2015. Accessed October 28, 2015.

6.    National Health Policy Forum. Medicare‚Äôs Post-Acute Care Payment: An Updated Review of the Issues and Policy Proposals. http://www.nhpf.org/library/issue-briefs/IB847_PostAcuteCare_10-05-15.pdf. Published October 5, 2015. Accessed October 26, 2015.