Rehabilitation interventions in the inpatient and outpatient settings are often required in older adults, to facilitate independent living in communities. In the older adult, hospitalization is a risk for disability, leading to decreased ability to live independently at discharge from the hospital. Hospitalization-associated disability (HAD) occurs in approximately one-third of patients aged above 70 years.1 This is a disability that is not present 2 weeks prior to hospitalization, and it could occur even after the illnesses causing the hospitalization are treated. Postacute care (PAC) in rehabilitation settings addresses this disability in the context of medical illness/disease.
Older patients are transitioned to rehabilitation settings for the management of disabilities caused by illness, injury, and/or hospitalization. A care transition is the movement of the patient from one healthcare setting to another. Older adults are at an increased risk of suboptimal care during care transitions. Rehabilitation professionals play a critical role in efficient and safe care transitions by determining the appropriate level of care based upon the intensity of services that older patients need. Medical and geriatric rehabilitation addresses the patient’s current functional status and rehabilitation goals with the intent to optimize the individual’s function, and facilitate independent living. The process involves addressing diseases, particularly multiple medically complex conditions in the context of disability. Based upon the intensity of services (including medical management and rehabilitation) required by the individual, the level of care setting is determined. Transitions of care may also be appropriate for older adults living independently in communities, when they require inpatient and outpatient rehabilitation.
This section focuses on the older adult population in the United States (individuals above 65 years of age), who are eligible for Medicare. Medicare is the federal health insurance program in the United States for people who are 65 years or older, certain younger people with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant. Traditional fee-for-service Medicare involved signihcant cost sharing from benehciaries. For that reason, more than 90% of Medicare benehciaries maintain supplemental insurance through their employer or private insurance, which also follows regulatory trends set by the Center for Medicare and Medicaid Services (CMS).2
Between 2009-2010, CMS implemented a Quality Improvement Organization (QIO) initiative, which demonstrated that Medicare benehciaries in communities in which QI initiatives were implemented to promote evidence-based care transitions, compared with Medicare patients in communities without this QI implementation, had lower all-cause 30-day re-hospitalization rates per 1000 and all-cause hospitalization rates per 1000, but no signihcant reductions in the rates of all-cause 30-day re-hospitalizations as a percentage of hospital discharges.3
In 2013, CMS incentivized ambulatory care providers to bill under new payment codes for transitional care management services to assist with transitions of care in the hrst 30 days of discharge from inpatient hospital settings.
On September 18, 2014, Congress passed the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act), which requires the submission of standardized data by long-term care hospitals (LTCHs), skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRFs).4
On October 29, 2015, CMS released a proposed rule that would require all hospitals and HHAs to develop a written discharge plan for every inpatient and specihc categories of outpatients within 24 hours of admission. This was the hrst step in implementing the IMPACT Act.5