Key Components of Post-Acute Care for Patients After Acute Illness or Injury
Post-acute care requires a multidisciplinary team approach with organized protocols focused on preventing complications, maximizing recovery, and ensuring successful transitions to reduce mortality and improve quality of life.
Core Components of Post-Acute Care
1. Multidisciplinary Team Coordination
- Specialized rehabilitation team including:
- Physicians (stroke specialist/physiatrist)
- Nursing staff
- Physical therapists
- Occupational therapists
- Speech-language pathologists
- Dietitians
- Social workers
- Psychologists (where available) 1
- Regular scheduled team rounds to discuss management strategy for each patient 1
- Coordinated care with clear communication across inpatient and outpatient settings 1
2. Comprehensive Assessment
- Systematic evaluation of:
- Residual neurological deficits
- Cognitive and communication status
- Psychological status
- Swallowing ability
- Previous functional ability
- Medical comorbidities
- Family/caregiver support 1
- Early identification of rehabilitation needs to reduce healthcare costs 2
3. Individualized Care Planning
- Development of rehabilitation plans addressing specific deficits 1
- Tailored care based on medical, social, and functional determinants of health 1
- Establishment of realistic therapy goals with patient and family involvement 1
- Early mobilization protocols 1
4. Complication Prevention and Management
- Protocols for preventing common complications:
- Venous thromboembolism
- Pressure injuries
- Falls
- Pain syndromes
- Infections 1
- Systematic assessment of post-discharge complications to reduce 30-day readmissions 1, 3
5. Secondary Prevention Strategies
- Addressing modifiable risk factors (e.g., hypertension, diabetes, dyslipidemia) 1
- Medication management and adherence support 1
- Lifestyle modification education (diet, exercise, smoking cessation) 1
6. Transition Planning and Discharge Support
- Early assessment of discharge needs 1
- Patient and family education on:
- Disease process
- Medication management
- Recognition of warning signs requiring medical attention
- Self-care techniques
- Available community resources 1
- Clear communication between hospital and next level of care 1
- Scheduled follow-up appointments 1
7. Community Integration Support
- Connection to community services:
- Exercise programs
- Fall prevention programs
- Behavioral health services
- Pharmacy services
- Support groups
- Nutrition and transportation services 1
- Early supported discharge with home-based rehabilitation when appropriate 1, 4
Models of Post-Acute Care Delivery
Hospital-Based Models
- Specialized rehabilitation units
- Daily multidisciplinary rounds (shown to decrease length of stay by 15% while maintaining quality) 5
- Specialized transition clinics (associated with nearly 50% reduction in 30-day readmissions) 1
Community-Based Models
- Early supported discharge with hospital-based team providing home services 1
- Home-based interdisciplinary rehabilitation programs 4
- Community health worker interventions 1
- Post-intensive care syndrome follow-up systems for critical illness survivors 6
Risk Factors for Poor Outcomes in Post-Acute Care
- Impaired functional status (HR 4.78) 3
- Increased medical acuity requiring complex interventions 3
- For-profit facility ownership (HR 1.43) 3
- Inadequate transitional care processes 3
- Mismatch between patient needs and available resources 3
Implementation Considerations
- Develop standardized protocols and clinical pathways for post-acute care 1
- Ensure staff receive appropriate training in post-acute care management 1
- Establish support systems for follow-up after discharge 1
- Create community resource networks to support patients after discharge 1
- Monitor outcomes including functional status, readmission rates, and quality of life 1
Post-acute care is a critical component of the healthcare continuum that significantly impacts patient outcomes. Effective implementation requires coordinated, multidisciplinary approaches with clear protocols and strong communication across care settings.