1. Inpatient Care Settings

2. Inpatient Care Settings
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The range of inpatient care settings is extensive. Health care professionals in these facilities serve the needs of people who are critically ill, require medical, surgical or psychiatric interventions, or ongoing nursing and rehabilitation services. The process of moving from one setting to another is very dynamic. Members of the physical therapy team, including the PTA, are often involved in these processes and have considerable impact on a patient’s recovery.

3. Inpatient Care Settings
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Acute Care Hospitals
Specialty Hospitals
Acute Rehabilitation Hospitals
Skilled Nursing Facilities
Inpatient care settings cover the spectrum from acute care hospitals—which include various types of intensive care units—to medical/surgical units, pediatric units, and specialty hospitals. Patients who no longer need the complex services of a general facility but are not well enough to return home are often moved to either a specialty hospital, such as an Acute Rehabilitation Facility or an Acute Long Term Care Hospital, or a Skilled Nursing Facility (SNF) where they can receive the medical and rehabilitative services needed to returned to their prior level of function (PLOF). Interventions and services offered at these less acute facilities help maximize each patient’s potential of returning home or to a lower level of care.
Long-Term Acute Care Hospitals

4. Common Elements Regulations Patient Rights Physician Oversight
Quality Assurance and Risk Management
Informed Consent
Employee Qualifications
All inpatient care settings have a number of things in common. Each is regulated by state and federal healthcare guidelines and requires physician oversight of patient services, including admission and discharge. As an employee of these types of healthcare institutions you must undergo background checks, verification of training and qualifications as well as orientation to specific institutional and department policies. Patients receiving care in these facilities have extensive personal rights and expectations and must provide consent for each procedure, test or intervention. Therapy services are no exception to this. Quality of services and management of risk factors are monitored on an ongoing basis to reduce negative outcomes in nearly all inpatient settings.

5. More care Less Care
Let’s examine standard descriptors of each level of care.

6. General Acute Care Hospitals
General acute care hospitals: This is the second largest group of inpatient beds, and is approaching 1 million in the United States. Nearly every rural and all urban communities have at least one general or regional acute care hospital. Larger communities may be served by a large network of hospitals such as Banner Healthcare or Kaiser-Permanente. Most general acute care hospitals have a minimum of one Intensive Care Unit (ICU). This is the setting within the hospital that is best prepared to meet the needs of a medically unstable patient. Depending on the size and location, the ICUs may have specializations for diagnostic specific conditions such as cardiac, cardiopulmonary, neurological, trauma, burns or pediatric. Patients whose medical conditions are stabilized but require monitoring and specialty services will transition to the acute medical or surgical section of a hospital. Many, but not all, general hospitals have an obstetric unit. Some acute care facilities provide psychiatric services. A common point of entry into the general acute hospital system is via the emergency department. Others are admitted directly to a medical unit or surgical unit following a surgical procedure. Physical therapy services within the general acute care setting are likely to be found in all patient care areas including the emergency department and the ICU.

7. Specialty Hospitals
Specialty hospitals are typically smaller than general hospitals and may be considered either a step down from the acute care setting, or an alternative to the larger general acute care hospital. Specialty hospitals don’t usually have emergency rooms, although some state laws will require that they do. Specialty hospitals are more likely to be ‘for profit’ (74%) than general hospitals. Specialty hospitals focus their delivery of care to specific diagnostic categories such as cardiac, orthopedic, surgical or women’s health.
The long term acute care hospital (LTAC) is a type of specialty hospital that serves a unique population of catastrophically ill patients who require extensive medical, respiratory and rehabilitative care. These facilities tend to be very small and selective about who they admit. Payment for services provided is significantly different than the acute care setting due to the complexity of the patient’s needs. Physical therapy services are essential in these facilities.
<<How is payment different?>>

8. Acute Rehabilitation Hospitals
Acute rehabilitation hospitals are either free standing hospitals, such as most HealthSouth facilities, or may be located within an acute care hospital. Patients are typically admitted to the acute rehab hospital from the acute general hospital. Patients should be medically stable and have the endurance to participate in rehabilitative services for a minimum of three hours a day. A medical doctor, often a physical medicine and rehabilitative (PM&R) specialist, is directly involved in each patient’s care.

9. Skilled Nursing Facilities
The largest section of inpatient care is provided within the skilled nursing facilities (SNF) on sub-acute units. According to the Centers of Disease and Disability, as of 2004 there were approximately 1.7 million skilled nursing beds in the US. These settings are unique in that they generally serve two specific, yet different, populations. The first is the sub-acute section, which receives patients from acute hospitals and specialty hospitals when the patient requires ongoing skilled nursing and therapy services. Admission to these facilities is covered for qualifying stays by Medicare A, Medicaid and most private insurance policies. Therapy services are an integral part of the sub-acute admission. The second part of SNFs typically have long term care beds which are occupied by people, often called residents, who are medically stable and have minimal to no rehabilitative potential. These residents are unable to live independently and require assistance for some aspect of their ADLs, IADLs, management of medications and ongoing monitoring. Medicare and most private health insurance plans do not cover long term care admissions. Therapy interventions and services are restricted due to limited potential to regain functional improvements.

10. Patients
These will be questions where students match the person with the setting. I don’t have answers yet.
Patient A: Stephan M. is a 20 y.o. who was involved in a head-on collision 2 days ago. His field Glasgow Coma Scale (GCS) was 5. He underwent an emergency craniotomy and is now on life support (ventilator).
Patient B: Martha H. is 85 years old and lives alone. She fell one week ago and sustained a right hip fracture and a left Colles fracture. The fractures were stabilized (ORIF) 5 days ago. Due to limited eyesight, intolerance to pain medication and extreme fear of falling she is being transferred to a ______________________ for continued inpatient therapy. Fill in the blank with the most likely facility.
Patient C: Harold S. is a 54 y.o. who underwent an Atrial Valve replacement surgery 3 days ago. His vital signs are normal and pain is being managed with medications. He is up ambulating with supervision. What type of facility are you most likely to see this patient in? Hint, there is more than one option for this patient.

11. Summary
Inpatient care settings cover a wide spectrum of service models to meet patient needs. Patients are admitted and discharged from the various levels of care based on their medical needs. Within each of these settings the physical therapist and physical therapist assistant can have significant impact on patient outcomes.