SNF, SAR, NH, ALF, and More Discharge Options: Interprofessional Education Series

Core IM

This episode breaks down our many different disposition options for patients.

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Subacute Rehabilitation in Skilled Nursing Facilities

  • Terminology 
    • SAR (subacute rehab) and SNF (skilled nursing facility) refer to the same disposition option and are often used interchangeably.
    • To break it down to semantics: Subacute rehab refers to the array of services that take place in a physical facility called a skilled nursing facility
  • Type of care provided
    • Specific skilled needs (such as PT or OT) that would be difficult or too complex to obtain at home
    • Notably, oversight is different than at the hospital, with one nurse assigned to many patients, and often sparser clinician (NP/PA/MD) supervision.
  • Coverage
    • Covered by Medicare and therefore, easier to get bed approved for patients with Medicare who quality based on nursing or therapy needs

Long-Term Care Facility or Nursing Home

  • Type of care provided
    • Nursing home patients require closer supervision with their daily activities (e.g. bathing, dressing, feeding, toileting) that they are not able to feasibly receive at home
    • Medication management and intermittent vital signs are performed by nurses, but these patients do not require intensive skilled care such as rehab services, IV antibiotics etc. like they may in subacute rehab
  • Payment
    • Covered by:
      • Out-of-pocket payment by the patient/family (usually referred to as a “spend down”)
      • A special form of insurance called a long-term care plan (paid into much like life insurance, but for the purpose of long-term care)
      • Medicaid if the patient qualifies (state specific requirements)
    • Not covered by:
      • “Traditional” private insurance plans
      • Medicare

Assisted Living Facility

  • Type of Care Provided
    • These facilities are highly variable in what services and level of support they provide residents and can have multiple different levels of care based on an individual patient’s needs
    • Aides are typically on-site 24-hours a day with one nurse who oversees their care of patients rather than a traditional nursing role
    • There are three levels of care provided at an assisted living facility
      1. Independent living or “senior” housing: most independent with residents living in their own apartment and partaking in meals and/or activities as they desire
      2. True “assisted living”: a la carte services available to assist with activities of daily living (ADLs) & independent activities of daily living (IADLs)  based on resident’s individual needs
      3. Memory care: higher level of supervision and oversight by nursing staff and aides for residents with moderate-severe dementia; often includes medication management and units often locked to prevent risks of wandering
  • Payment: can be very expensive depending on the support needed.  Vast majority are paid out of pocket, though some states have a certain number of apartments per facility that are reserved to support lower income patients

Acute Rehab

  • Type of Care Provided
    • To qualify, patients must be able to participate in 3 hours of combined skilled therapy (e.g. PT, OT, speech & language therapy) per day which is a big distinction compared to a SAR and often not possible for older adult patients with multiple chronic medical conditions
    • Typically shorter stays (e.g. acute stroke) with plan to transition to SAR or home once more intensive therapy goals are met
  • Payment: Medicare or private insurance

LTACH (Long-term Acute Care Hospital)

  • Type of Care Provided
    • The most acute level of care besides an inpatient hospital stay
    • Requirements for admission are facility/insurance dependent, but usually require complex management and intensive clinician oversight (e.g. tracheostomy care, vent management, severe wound infections requiring complex management)
    • Typically a MD is in-house 24/7 and there is a lower nursing:patient ratio than in other types of after-hospital facilities described above
  • Payment
    • Medicare or private insurance

Home with services:

  • Type of Care Provided
    • Must be able to maintain some level of independence or to the care of family or home health aides if requires more intensive care
    • Skilled services can be performed by visiting nurses, physical or occupational therapists, speech and language pathologists (SLP) if an attending physician certifies the need through completing a Medicare Face to Face on discharge
    • A Face to Face is a form required by Medicare that certifies that the patient is “homebound” (has reasonable hardship getting out of the home for office visits for services), has a diagnosis that requires skilled services, which services are required
    • It is also helpful to include who the consulting skilled provider should call with issues as well as symptoms or parameters for when to call  
  • Payment
    • Skilled services are paid for by Medicare or private insurance
    • Home health aide support for ADLs/IADLs typically paid for out of pocket or through Medicaid


Shreya Trivedi, MD - Author, Producer

Gabrielle Mayer - Author, Producer

Ryan Chippendale, MD - Author, Producer

Todd Selmer, RN - Guest Expert

Drew Grabham, LCSW* - Guest Expert

Susan Hedlund - Guest Expert


Colleen Christmas, MD

Anna Goroncy, MD

* Drew Grabham reports that he is a board member of Portland Street Medicine.

Those named above unless otherwise indicated have no relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Release Date: June 3, 2020

Termination Date: June 3, 2023

CME Credit

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The American College of Physicians designates each enduring material (podcast) for 0.5 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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