top of page

Healthy Seniors


The Hospital to Rehab Center Journey Explained

If you are hospitalized, you might be told the next step, before going home safely, is additional care-perhaps in a skilled rehab center, sometimes referred to as a post-acute facility. These facilities bridge your recovery from hospital to home, so you are stronger and more prepared to take care of yourself at home and get back to your daily activities of living and your own routine.

A center should provide a multidisciplinary approach to your care which involves you, your physician and your family. The center will work toward your safe discharge goal from the day of admission.

Intensive rehabilitation, including physical, occupational, and speech therapy, should be offered by in-house therapists. Their focus should be on maximizing your functional abilities so you will be stronger, more confident and able to care for yourself as independently as possible. They may also work with your loved ones, so they can help with any lifestyle or home changes.

Comprehensive medical services or skilled nursing services are provided, under the direction of your physician, such as wound care, respiratory services, tracheostomy care and weaning, tube feeding, intravenous therapy, pain and medication management. Dietary management and guidance is also offered, especially if you have a new diagnosis or special dietary requirement.

Your length of stay at the facility will be determined by your insurance coverage and how well you are progressing in your rehab journey. Medicare allows 100 days, of in-patient rehab services, however you will need to show that you are making progress, or insurance may only cover you for a portion of that 100 days.

For Medicare, days 1-20 will be covered in full and at days 21 you will be given a copay (the copay amount will depend on if you have a secondary insurance coverage, ask your rehab facility what your specific cost will be at day 21).


If you find that you are discharged home, from a skilled nursing facility, and struggling, you may be able to readmit to a rehab facility and use the additional of your 100 days (again still determined by your progress). Your 100 days will only reset once you have been out of the hospital, or rehab facility for a full 60 days. Your social worker, or case manager, at the hospital should be able to tell you what you can qualify for regarding a post-acute facility, before you are transferred. Usually your social worker at the nursing center will set you up with insurance covered home therapy or outpatient therapy at time of discharge.

Discharge processes may be different at each center, but can include a home visit (to make sure you are fully prepared for life at home), a care conference with you to talk about home life and your options. You may need additional help (ie, home care or private duty care), ordering of/or installing any new medical equipment you may now need, or information on additional housing resources that may be more safe then returning home (ie Assisted Living, Memory Care, etc).

bottom of page