The Transition from the Hospital to an Inpatient Rehabilitation Setting for Neurologic Patients

Nurs Clin North Am. 2019 Sep;54(3):357-366. doi: 10.1016/j.cnur.2019.04.004. Epub 2019 May 24.


Transitions of care from acute hospitalization to postacute rehabilitation settings evolved as a function of cost-saving changes to the Medicare Prospective Payment System. Restricted criteria for inpatient rehabilitation facility admission limited access for patients with severe physical and cognitive deficits. Once used as a resource-intense supplement to hospital care, skilled nursing facilities have metamorphosed into rehabilitation settings with limited nursing staff, lower intensity of therapies, and decreased community discharge rates. A collaborative approach to care transitions, using acute and postacute health care providers, provides the opportunity to improve this process. Early physiatry consultation is a strategy for patients with neurologic disease.

Keywords: Care transition; Inpatient rehabilitation facility (IRF); Nursing; Physiatry; Physical medicine and rehabilitation; Rehabilitation; Skilled nursing facility (SNF).

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Critical Care / standards*
  • Humans
  • Nervous System Diseases / rehabilitation*
  • Patient Discharge / standards*
  • Patient Transfer / standards*
  • Practice Guidelines as Topic*
  • Rehabilitation / standards*
  • Transitional Care / standards*
  • United States