Rehabilitation sites of care

Rehabilitation site	Level of care requirements	Therapy services	Primary funding source
Inpatient rehabilitation (acute) Freestanding rehabilitation hospital or rehabilitation unit attached to acute hospital	24 hours/day availability of a physician with expertise in rehabilitation 24 hours/day nursing care Intensive interprofessional team rehabilitation Reasonable expectation for improvement	PT/OT/ST Must tolerate 3 hours of therapy 5 days/week of at least 2 or more therapy services A multidisciplinary team conference is required	Medicare part A Days 1 to 60: full coverage Days 61 to 90: partial coverage but daily co-payment >90 days: daily copayment for up to 60 lifetime reserve days More than lifetime reserve days: no coverage
Skilled nursing facility (subacute/transitional care unit)	Physician visit within 72 hours of admission On-call physician access 24 hours/day on emergency basis 24 hours/day nursing care Less intense therapy than acute rehabilitation Interdisciplinary team coordination	Skilled nursing care and/or straight-forward rehabilitation Must have skilled need (PT/OT/ST, wound care, IV antibiotics, new G-tube) Daily therapy up to 1 to 2 hours, 5 days/week or as tolerated	Medicare part A Days 1 to 20: full coverage Days 21 to 100: partial coverage with co-insurance or co-payment, as long as skilled need remains active and has not reached plateau >100 days: no coverage
Skilled nursing facility (long-term care)	On-call physician access 24 hours/day on emergency basis Physician visit at least every 30 days for the first 90 days after admission, then at least once every 60 days thereafter 24 hours/day nursing care	ADL assistance and/or skilled nursing care Generally no skilled rehabilitation, but may use restorative nursing aide (RNA) program for ambulation	Medicaid Private pay Long-term care insurance
Long-term acute care hospital (LTACH)	24 hours/day physician availability and daily visits (may have specialized consultants including pulmonologists) 24 hours/day respiratory therapy on-site Chronic skilled care, active medical conditions Respiratory care needs (chronic ventilator-dependent)	PT/OT/ST available	Medicare part A
Home health	Intermittent skilled services for persons who are homebound^* Requires face-to-face physician visit within 30 days of ordering or 90 days prior to start of care, recertification every 60 days	PT/OT/ST skilled nursing, social worker, home health aide available Typically 1 to 2 visits/week for several weeks depending on need and tolerance level	Medicare part A
Outpatient (hospital-based or independent)	Physician referral and recertification Rehabilitation services	PT/OT/ST available Typically, 2 days/week based on need, tolerance level and rehabilitation goals Cannot have home health and outpatient therapy services simultaneously	Medicare part B

ADL: activities of daily living; IV: intravenous; OT: occupational therapy; PT: physical therapy; ST: speech therapy.

* CMS guidelines state that patients are considered "homebound" if they meet both of the following 2 criteria:

The patient must either, because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence or have a condition such that leaving their home is medically contraindicated.
There must exist a normal inability to leave home, and leaving home must require a considerable and taxing effort.

References:

Harper GM, Lyons WL, Potter JF (Eds). Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 10th ed, American Geriatrics Society 2019.
Reuben DB, Herr KA, Pacala JT, et al (Eds). Geriatrics At Your Fingertips, 25th ed, American Geriatrics Society 2023.
Centers for Medicare and Medicaid Services. Medicare Benefit Policy, Publication no. 100-02, Department of Health and Human Services 2014.

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Rehabilitation sites of care