13 Things to Know About Subacute Rehab (SAR)

SAR Services

SAR provides help in two different areas:

Licensed physical, occupational, and speech therapists provide therapy to increase your strength and functioning. For example, depending on what your need is, they might work to:

• Increase your balance
• Improve your safety when walking
• Help you move your legs again after a stroke
• Improve your independence with activities of daily living (ADLs)
• Improve your cardio (heart) fitness after a heart attack

Licensed nursing staff provides medical care such as:

• Wound management
• Pain management
• Respiratory care
• Other nursing services that must be provided or supervised by a registered nurse (RN) or licensed practical nurse (LPN)
  

Who Benefits From SAR?

People who have experienced a fall, injury, or medical condition may benefit from a brief stay at a SAR facility.

The goal of SAR is to provide time-limited assistance designed to improve functioning and safety at home or the previous place of living (such as an assisted living or independent living facility).

People receive SAR for a wide variety of conditions, including:

• Joint (hip, knee, shoulder) fractures or replacements
• Cardiac conditions
• Stroke
• Diabetes
• Deconditioning related to a fall
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure (CHF)
• Spinal cord injuries
• Cancer
• Amputation

Therapy at a SAR

Your healthcare provider will typically order therapy for you based on the recommendation of the physical therapist, occupational therapist, and/or speech therapist.

Some people can tolerate only about 30 minutes a day at first, depending on their condition. Others may be able to tolerate multiple hours a day of therapy. SAR usually will provide up to about three hours of therapy per day.

If you're at a SAR facility and feel as if you should be getting more therapy per day, ask your healthcare provider if your therapy minutes can be increased.

Length of Stays

SAR stays vary greatly. Some people are only there for a few days, while others may be there for weeks or even up to 100 days.

A variety of factors determine how long you might stay at a SAR facility, including:

• The extent of your injuries or medical condition
• Your overall health
• The length of time your insurance approves
• Your ability to live safely after you leave the SAR

SAR vs. Acute Rehab vs. Hospital

The terms used to talk about medical care and rehabilitation can be confusing at times. SAR is different from a hospital or an acute inpatient rehabilitation center.

A hospital, which is sometimes called "acute care," is appropriate only for significant medical issues with the goal of a very short stay.

An acute rehab center is designed for high-level rehab needs, typically requiring three hours a day of physical, occupation, or speech therapy per day five days per week.

Finding a High-Quality SAR

One of the challenges in rehabbing after a stroke, for example, is choosing an excellent program in which to rehab. Doing research ahead of time before you or your loved one ever needs rehabilitation can be very helpful.

Centers for Medicare and Medicaid (CMS) provide a 5-star rating system on nursing homes, and many of those facilities provide SAR. Comparing the ratings of different facilities can be very helpful. 

Typically, your most valuable resource will be recommendations from loved ones or friends who have already been through this process. Their personal experience is invaluable.

If you have time, it can also be helpful to stop by a few different facilities and ask for a tour. Watching how the staff interact with the people in their care can be an important indicator of the quality of care provided.

Remember that even though some buildings can look brand new, it's the program and people caring for you that really will influence your experience there.

Choosing a SAR Facility

If you need SAR, be aware that many times, you do have a choice of where this SAR is provided.

Hospitals frequently will steer you toward their own SAR programs if they are affiliated with one. While this may be a good option, you do have a right to decide where you would like to rehab.

Your options may, however, be limited by whether your insurance classifies the facilities you choose as in or out of network, and whether those facilities choose to accept you into their program.

Paying for a SAR

If you need some rehab because of a decline in strength from a fall, hip fracture, or medical condition, SAR may be a benefit for you.

SAR is typically paid for by Medicare or a Medicare Advantage program. Medicare is a federal insurance program that you pay into over the years as you work.

Medicare Advantage programs are private groups that essentially manage people who are eligible for Medicare but have opted to choose to be part of these groups.

Financial coverage and requirements vary, depending on which plan you have chosen.

Leaving Early

If you think you're ready to go home before the medical staff thinks you should, you do have the right to leave the facility at any time.

If the healthcare provider feels strongly that you are not safe to leave yet and you choose to leave anyway, they will likely ask you to sign a form that says you are leaving against medical advice (AMA).

This means that although they can't make you stay, they don't believe you're safe to go home yet. It's protection for the facility because, without that documentation, they could be liable for harm that occurred because of your early discharge.

Insurance Coverage Ending

Most insurance companies monitor the use of SAR closely, with facilities having to perform detailed assessments frequently and receive both prior and ongoing authorization to provide SAR to its members.

Once it's been decided that your SAR coverage is ending, you must receive advance notice of this denial of coverage.

This is sometimes called a "cut letter" or "denial notice," and a copy must be provided to you and kept on file at the facility to prove that you were given notice of this change before it occurred.

Coverage might end for a variety of reasons, including:

• You no longer require skilled therapy or skilled nursing services.
• You're not able to participate in the therapy services (such as if your memory is impaired by dementia).
• You continuously choose not to participate in therapy services.
• You've used up your allotted number of days for SAR.

If You're Not Ready to Go

After being told that the insurance coverage is ending for your SAR stay, people often make plans to go back home or to their previous facility in the next couple of days.

While you may be eager to go home, it's also possible that you could be very concerned that you're not strong enough yet to go home.

If you feel that your insurance coverage should not be ending yet, you are allowed to appeal this denial of coverage. You can request an expedited appeal so that you will have an answer quickly.

Directions for appealing will be included in the denial of coverage notice that you receive.

If you choose to appeal, the facility will provide the insurance company with your relevant clinical information and they will approve or deny your appeal for additional SAR coverage.

If You're Not Safe to Go Home

Sometimes, despite your best efforts at rehabbing at a SAR facility, you might not gain enough strength or functioning to be safe at home right away. Not being able to meet your goal of going home can, of course, be discouraging.

The SAR social worker will help you look at other options which may include transitioning to a skilled nursing facility, like assisted living or an adult foster care home.

They may also be able to work with your family members and community agencies to provide additional assistance at home to increase the safety of this option.

Remember that some people do take longer to heal and regain functioning than others, so it's important that you continue to work to maintain and improve your strength, wherever you live.

For example, you might still be able to receive a lesser level of therapy services through Medicare Part B at a skilled nursing home which may make it possible to return home in the future as you slowly gain functioning.

Help at Home

It's common to continue to need help at home for a time after SAR. The goal of SAR is ideally to help you return to your previous level of functioning.

However, since many insurance companies try to limit the costs that they pay out for their clients, a more practical goal at SAR may be to help you be safe and strong enough to go back to your home and then continue rehab there.

Before you're discharged from SAR, the facility should provide referrals and make arrangements for you to receive ongoing care such as home health services, provided you agree to these support services. 

Home healthcare agencies can assist you at home with physical therapy, occupational therapy, speech therapy, professional nursing care, and medical social work services.

Using these community resources can help you successfully transition back home, which is the shared goal of both you and the SAR staff who have been working with you.