Continuum of Care Information

Acute Care Hospital

+ Acute care hospitals are short-term medical care settings that aim to deliver immediate
and crucial medical care with the goal of discharging patients once treatments can be
safely provided at a lower level of care setting.
+ Acute care is for patients who are diagnosed with a new onset of illness or disease,
ongoing long-term illness or disease, or those recovering from major surgery or medical
complications that need immediate care.
+ Acute care patient care is usually shorter in its duration. While the average length of stay
depends on the diagnosis, patients covered by Medicare experience and average
between 5.2 days and 3.8 days.

Long Term Acute Care Hospital

+ Long-term acute care hospitals (also known as LTACHs) are facilities that specialize in
the treatment of patients with complex and serious medical conditions that require
ongoing care, but no longer require intensive care or extensive diagnostic procedures.
+ Individuals may be referred to LTACHs if they:
+ Need more recovery time in a hospital setting
+ Require physician follow-up daily
+ Have a acute condition that should be seen by specialists
+ Individuals typically come directly from an acute care hospital and may stay at an
LTACH from 10-40 days before leaving for a lower level of care or home. An LTACH
facility is more equipped to meet the complex medical needs of an individual than what
might be received at an inpatient rehab center, skilled nursing facility, or home.
+ In addition to 24-hour nursing care, individuals usually receive 1-3 hours of rehabilitation
therapy a day to help start their recovery process.
Inpatient Rehab Services

+ Inpatient rehab centers use an interdisciplinary team approach to coordinate medical

treatment, specialized services, therapy services, and other rehabilitation treatments, all
while providing support and encouragement to help the individual make the best
recovery possible.
+ Individuals must be able to participate in a minimum of three hours of therapy per day,
which is made up of occupational therapy, physical therapy, and/or speech therapy.
+ Individuals usually come directly from an acute care hospital or an LTACH. The length of
stay at an inpatient rehab center is dependent on the diagnosis and severity of
symptoms, however the average length of stay is typically 15 days.
+ Therapy services work on providing the highest possible quality of life, whether it be in
returning to work, school, recreational activities, or participating daily living activities.

Skilled Nursing Facilities

+ Skilled nursing facilities are defined as a healthcare institution that 24 hour nursing care,
has a physician on staff, can store and dispense medications, and facilitate participation
with meals and personal hygiene.
+ Individuals usually come directly to skilled nursing facilities from an acute care hospital
so that they can recover or heal from an injury, illness, or surgery. The goal of skilled
nursing facilities are intended to be a short term stay and help the individual return
home. However, some individuals remain at the skilled nursing facility for long term care
depending on outside circumstances, complications, and/or family choice.
+ In addition to nursing care, individuals receive physical, occupational, and/or speech
therapy services. However, the requirement of how much therapy is less than an
inpatient rehab setting due to amount of therapy a patient can tolerate.
+ Therapy services can focus on activities of daily living, maintaining or returning level of
function, education on energy conservation and task simplification. They can address
the use of adaptive equipment, home modifications, and how to safely pursue regular
activities in order to improve or maintain quality of life.
Outpatient Services

+ Outpatient clinics come in many different shapes and sizes. They provide care to a wide
range of clients with a variety of etiologies. Outpatient clinics can see patient populations
from children specific, adult specific, or a combination of both.
+ Outpatient clinics provide physical, occupational, and/or speech therapy services for
individuals who are not currently admitted to a hospital or care facility. They may have
previously stayed at an acute care hospital for an injury, illness, or surgery, but no longer
need 24 hour nursing care or to stay at an inpatient facility.
+ Outpatient clinic therapy services work towards improving daily mobility, daily activities,
and quality of life, but individuals are currently independent enough to receive these
services while living in their home of community.
+ There are specialty outpatient clinics that provide other types of services, such as pre- or
post-surgery rehab, biofeedback, aquatic therapy, hippotherapy and more. Outpatient
clinics are also a great option for services that are not offered within the community or
school system.

Home Health

+ Home health care services are considered medical care provided at an individual’s
home. Home health care encompasses a range of skilled medical professionals,
including nursing care, physical, occupational, and or speech therapy.
+ Home health care is often prescribed as a part of the plan of care following a
hospitalization or lower level care facility stay.
+ To qualify for home health care, an individual must qualify under the specific criteria by
the CMS (Center for Medicare & Medicaid):
+ Be considered homebound.
+ Required skilled care to improve, maintain, prevent, or further slow the health
condition.
+ Be under the care of a physician who checks status within 3 months of start of
home health care.
School Based Therapy

+ School-based therapy services can include physical, occupational, and/or speech

therapy. The services a student receives are dependent on the IEP (individualized
education plan). Teachers, therapists, and parents meet to discuss the student and
his/her eligibility for special education or therapy services. Students are eligible for
school-based therapy services from age 3-21.
+ The goal of a student’s IEP is to support the student’s ability to participate in desired
daily school activities, promoting academic achievement, encouraging positive behaviors
necessary for learning, and prepare them for further education, employment, and
independent living.
+ Therapists in school-based therapy services collaborate to identify a student’s annual
goals and determine services, modifications, and accommodations to ensure a free and
appropriate education for students Interventions within school-based therapy may
include determining the least restrictive environment, functional and safe mobility,
access to participation in educational activities, speech difficulties, and daily activities of
living.

Early Intervention

+ In every state, children from birth to age 3 can receive early intervention services to
address developmental delays or specific health conditions.
+ Early intervention services provide a range of services in order to help children catch up
and meet developmental milestones while increasing the chances for success in school
and life overall.
+ Early intervention services are federally mandated programs, through IDEA (Individuals
with Disabilities Education Act), and provide services to the age of 3 where children are
then eligible for school-based therapy.
Independent Living

+ Independent living communities (also known as retirement communities, senior living

communities or independent retirement communities) are housing designed for seniors
55 and older.
+ Independent living communities are permanent living situation for individuals who can
still live independently but enjoy having access to assistance when needed. Optional
assistance may include access to dining, medical care, housekeeping, laundry and
more.
+ Independent living communities commonly provide apartments, but some also offer
cottages, condominiums, and single-family homes. Residents include seniors who do not
require assistance with daily activities or 24/7 skilled nursing, but may benefit from
convenient services, senior-friendly surroundings, and increased social opportunities.

Assisted Living

+ Assisted living communities are for 55+ seniors who do not need around the clock
medical care. While they still need basic services, they can still live independently.
Assisted living facilities often provide a permanent residence for seniors
+ Residents at assisted living communities are free to live an independent lifestyle, but
also receive regular support for a range of daily activities ranging from cleaning to meal
preparation. Housekeeping and maintenance services are often included in the monthly
rental of an apartment, along with laundry services, utilities, transportation and meals.
+ In addition to enjoying the peace of mind that comes from this maintenance-free
lifestyle, residents can take advantage of a full calendar of events, activities, out-trips,
and countless opportunities for social engagement. Additional care services, such as
medication management or assistance taking a shower, are also readily available.

Long Term Nursing Home

+ Long Term Nursing Home is often a permanent residence for individuals who need 24-
hour care, but do not require a hospitalization. These facilities provide nursing care,
three meals a day, and assistance with everyday activities and self-care tasks. In-house
physical, occupational, and/or speech therapy services may also be available.
+ Some long-term nursing home facilities are connected with a short-term skilled nursing
facility. For individuals who come from an acute care hospital to a skilled nursing facility
 but are unable to return to living at home due to ongoing physical or mental conditions,
long term nursing homes are a good option to provide constant care and supervision a s
their services focus on medical care more than most assisted living facilities.

Palliative Care/Hospice

+ Palliative care is specialized medical care for an individual with a serious illness. This
type of care is focused on providing relief from the symptoms and stress of a serious
illness. The goal is to improve quality of life for both the individual and the family. It is
appropriate at any age and at any stage in a serious illness, and it can be provided along
with curative treatment.
+ Hospice is specialized type of care for those facing a life-limiting illness, their families
and their caregivers. Hospice care concentrates on managing a individual’s pain and
other symptoms so that they may live as comfortable as possible and make the most of
the time that remains while addressing individual’s physical, emotional, social and
spiritual needs. Hospice care takes place in the individual’s home or in a home-like
setting.

Bridge Hospitals

+ A pediatric bridge hospital is a specialty care hospital that assists children and families in
the transition from acute care hospital to home.
+ The Bridge Model is a person-centered, social work-led, interdisciplinary model of
transitional care. Bridge hospitals emphasizes the collaboration among hospitals and
community-based providers to ensure a seamless continuum of care. They meet the
need for subacute, traditional care, within a transitional rehabilitation pediatric setting.
+ A pediatric bridge hospital usually serves children 2 weeks to 21 years of age. These
children typically have a range of complex medical conditions from brain injuries to
complications from birth.
+ A pediatric bridge hospital is typically an inpatient facility that incorporates nursing care,
education facilitation, physical, occupational, speech, respiratory, and recreational
therapy services, as well as some outpatient services.