Rehabilitation Care at Home and its Value to Communities and Hospitals

In 2017 Contessa introduced a unique alternative to subacute rehabilitation (SAR) and traditional skilled nursing facilities (SNFs): our Rehabilitation Care at Home program. Now into its sixth year, the value of this program to local communities and hospitals continues to shine. This is especially evident in an era of historic SNF bed shortages that has resulted in frustration for patients who need SNF placement and for hospital systems who rely on these facilities as a resource to move patients to. 

Rehabilitation Care at Home offers a ready-made solution for these challenges, and it is also returning excellent outcomes for all stakeholders involved. Because of this, it is a clear leader in skilled nursing care moving forward, and more hospital systems recognize this every day. 

Traditional skilled nursing facilities and their impact 

To understand the ways in which Rehabilitation Care at Home positively impacts communities and hospitals, it’s helpful to first understand how traditional SNFs impact health systems and patients. 

In a typical scenario, some patients at the end of their hospital need to be transferred to a SNF for continued care and rehabilitation activities such as physical therapy (PT), occupational therapy (OT) as well as skilled nursing care and other services. With the current healthcare workforce shortage, SNFs have struggled along with the rest of the industry; in a survey conducted by the American Health Care Association, 87% of SNFs reported facing moderate to high staffing shortages. 

The resultant difficulties in maintaining open staffed beds have led to bottlenecks in discharging patients to post-acute care, and to hospital admissions for patients whose physicians have recommended SNF placement from home for supportive care. 

Health systems looking for solutions have resorted to approaches such as opening in-hospital SNFs to provide care to patients. This requires an infrastructure (including staffing and square footage) and an approach to administration that falls outside of the normal course of hospital business operations. That health systems are taking it on despite these challenges shows how serious this issue has become for local and regional communities. 

Rehabilitation Care at Home and its value to health systems 

In contrast, when Rehabilitation Care at Home is adopted by a health system, the positive impacts for the providers and patients are immediate. When a hospitalized patient needs SNF-level care and they are found to be appropriate for home placement, there is no waiting period to get into their own living room. Many times, family can even transport them safely, and they can go straight home to receive the supportive services that are a part of the program. 

Alongside the benefit of being able to move patients quickly, health systems find that Rehabilitation Care at Home is a cost-effective solution to the challenge of creating available post-acute beds. There is a unique advantage to building a SNF at home program; the beds already exist and creating a 20-bed unit quickly—in a month or two—requires minimal overhead.  

Additionally, because of the end-to-end care coordination inherent in Rehabilitation Care at Home’s 60-day episodes of care, hospital systems enjoy greater transparency in ensuring patients are being discharged from SNF-level care to appropriate follow-up care, avoiding unnecessary readmissions to the hospital as a result.  

Rehabilitation Care at Home and its value to communities 

Patients who are admitted to a traditional facility face many of the same challenges as patients who are admitted to the hospital: lack of empowerment in their care, disconnection from their social support networks and decreased engagement in ownership of their own health.  

We see this especially in patients who may be frail with multiple comorbidities. For these patients, entering a hospital or facility can be a life-altering event. For some patients, it may even contribute to a final downward spiral in their health, partly because the facility may be disorienting for them. This could in turn make them more prone to mental deterioration and lead to them becoming more dependent. 

Because the duration of the stay in a SNF is even longer than a hospital stay, these problems are then compounded over a longer period of time. 

In contrast, patients who go home with SNF-level care can be more ambulatory and more upright and engaged. They’re also in more familiar surroundings with access to their families and social support. For those reasons, they tend to have less functional decline.  

In particular, the aforementioned 60-day care episode has enormous positive impact on outcomes of care for patients. Rather than the typical 30-day episode standard in SNF care, patients enrolled in Rehabilitation Care at Home spend 2-3 weeks in an acute phase of care and then the remainder of the 60-day episode in a transition monitoring phase. During this episode, they receive the additional benefit of cross-specialty coordination of care, careful check-ins and follow-up using protocols that decrease opportunities for communication breakdowns and reduce healthcare fragmentation.  

This leads to positive outcomes such as: 

• Decreased readmission rates 
• Decreased complications of care 
• Increased patient satisfaction scores 

Rehabilitation Care at Home and the Quadruple Aim of healthcare 

The orchestral services Contessa offers through this program clearly benefit its participants in many ways. What we have found consistently is that working closely with patients and their families in the home environment eliminates siloed care and coordinates all the voices involved so that the choir sings for the patients’ benefit. 

Ultimately, this value that Rehabilitation Care at Home creates for communities and health systems reflects its importance in meeting the “Quadruple Aim” of healthcare: to enhance the patient experience, reduce the cost of care, increase provider satisfaction and improve population health. It’s no wonder then that it is poised to become the gold standard for post-acute care going forward.