Post-acute care plays a critical role in the health care delivery system. By providing essential medical and rehabilitative care to individuals following an acute hospital stay, post- acute care providers contribute to improved outcomes while reducing health care costs. The post-acute continuum of care includes inpatient rehabilitation facilities (IRFs), long term care hospitals (LTCHs), skilled nursing facilities (SNFs), and Home Health Agencies (HHAs).
Hospital case managers provide guidance and support for patients and their caregivers as they identify and transition to their next care setting. Successful case management includes communication and coordination with post-acute care providers and home and community-based services and the development of a discharge or transition plan that addresses the patient’s goals, needs and treatment preferences, prepares patients and caregivers to participate in post-discharge care.