Rehabilitation Care at Home: Beyond Home Health

Traditionally, patients that require medically-necessary rehabilitation care are offered placement in a skilled nursing facility (SNF) or subacute rehab (SAR) to receive these services. In these instances, traditional home health would not typically be considered since home health generally supports patients with more chronic needs and is not structured to manage the more intensive needs of a skilled nursing facility patient. 

With this in mind, the novel concept of bringing patients home to receive skilled nursing facility-level care may be intriguing for health systems and referring physicians. This is especially true in an era of worrisome SNF closures. Distinct from home health, at Contessa this innovative model of care, called Rehabilitation Care at Home, is part of a continuum of high-quality medical services in the home that are redefining medicine. It has resulted in excellent patient outcomes and can be a useful component of value-based care solutions. 

Understanding Rehabilitation Care at Home vs. home health 

Unlike home health, which is a home-based health management system for homebound patients who need intermittent skilled care for their medical needs, the goal of Rehabilitation Care at Home is to meet the needs of patients who have had an acute deconditioning event. 

To accomplish this, Rehabilitation Care at Home meets the Centers for Medicare and Medicaid Services (CMS) criteria for medical necessity for skilled nursing care. This level of care goes beyond a typical home health program, where a nurse might visit a patient weekly or a few times per week at most, depending on the patient’s needs.  

Patients who require acute rehabilitation oftentimes require a higher frequency of medication administration, wound care and treatments like parenteral nutrition. This is combined with intensive rehabilitation therapies like physical therapy, occupational therapy and speech therapy. Rehabilitation Care at Home brings all this home.  

By definition then, Contessa is looking for patients who exceed typical home health needs, and Rehabilitation Care at Home is functionally an avoidance option for patients to receive SNF or SAR care at home.  

Rehabilitation Care at Home as an essential value-based care offering 

When looking at this program from a broader perspective, its robust structure, integration with Contessa’s continuum of care in the home and coordination with other healthcare providers is what sets it apart.  

In our 60-day risk-bearing bundle of care, we’re able to offer something that no other at-home post-acute program does: value-based care initiatives that help hospital systems improve care outcomes. With the current push by CMS to achieve these improved outcomes by elevating value-based care models, Rehabilitation Care at Home is poised to be a robust choice for hospital systems looking to build effective approaches to post-acute care.  

With this 60-day episode, patients typically spend 2-3 weeks in an acute phase of care, receiving intensive therapies, skilled nursing and other appropriate services. From there, they transition to a monitoring phase, where our care teams address the usual drivers of readmission and complications. With monitoring during this extended period, we manage medication regimens, coordinate follow-up consultations and weave more traditional home health elements into the care as needed.  

The full care continuum and end-to-end care coordination 

Whether a hospital system adopts this value-based 60-day bundle of care or chooses a non-bundled approach, our program offers supported transitions for patients. High-quality medical care in the home doesn’t just have to end with Rehabilitation Care at Home. In fact, it doesn’t have to even start there.  

Contessa’s Comprehensive Care at Home continuum offers a full suite of services in the home, from Recovery Care at Home to Palliative Care at Home. It brings hospital-level care home for select patients, as well as primary and palliative care options for conditions that require long-term chronic disease management.  

With our parent company Amedisys, Contessa can also bring home health services to the table outside of the Rehabilitation Care at Home offering. This added value helps hospital systems who are looking for options to offer this service as part of the full continuum.  

To achieve all of this, end-to-end care coordination is an essential component of Rehabilitation Care at Home. Patients discharged from the program may transfer to another level of care within Contessa’s care-at-home spectrum or continue their care through a community-based primary care provider. No matter how they conclude their stay, these patients are afforded careful care management that assures they are receiving appropriate resources and follow-up care. This helps to avoid costly complications and readmissions. 

Better outcomes for patients and health systems 

Ultimately our patients do very well with our medically supervised Rehabilitation Care at Home program. Our data consistently shows reduced readmissions, low rates of care complications and high patient satisfaction scores. 

This isn’t surprising considering what Rehabilitation Care at Home does for patients beyond the administrative structure of the care. The nature of care in the home eliminates detractors from care that are hard to avoid in a facility-based care setting. Take an older patient, for example. Often, removing them from their home environment exacerbates any latent delirium or disorientation. Coupled with isolation from their families, this can create a miserable experience for them, to the degree that they don’t take part in therapy in a way that is ideal. 

Bringing care home resolves these concerns. Because ultimately, patients don’t care about the structural details of their program. They care about their quality of life, about feeling healthy and being home in the environment that they know and are comfortable in. From this perspective, our patients gain many practical benefits by receiving their post-acute care in the home. We’re able to help show their families members how to take care of them and allow them to be part of their care experience. We find ways to support their home environment to set them up for success after their stay in the program is complete. 

In this way, this modality of post-acute care can redefine both the patient and experience and long-term patient outcomes—a goal that benefits everyone who seeks extraordinary care, whether they are delivering it or receiving it.