Continuum of Care

About Continuum of Care

Post-acute care — often provided at inpatient rehabilitation facilities, long-term care hospitals, skilled-nursing facilities, and at patients’ homes — is vital to the health care delivery system. These providers deliver essential medical and rehabilitative services following hospital care. Hospital case managers help support, and connect patients, families, and caregivers through communication and coordination with post-acute care providers and home and community-based services. This includes the development of a discharge or transition plan that addresses the patient’s goals, needs and treatment preferences, and prepares patients and caregivers for post-discharge care.

IRF Review Choice Demonstration

The Centers for Medicare & Medicaid Services (CMS) recently introduced the Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facilities (IRFs) in Alabama, with plans to expand the program to California in the near future.