Post-acute care is a key element of the healthcare system for older adults and an important strategy for maintaining their health. Compared with younger adults, older adults are more likely to have various comorbidities and disabilities and typically require a longer time to recover from acute illness. Cost considerations strictly limit the number of days of hospitalization, which limits the opportunities for older adults to regain their health following illness. Post-acute care models were therefore developed to meet the need of older adults for post-illness recovery. An important aspect of post-acute care is treatment outside a medical center, which enables patients to continue to receive appropriate care after completing treatment for an acute illness and to help them regain the autonomy they enjoyed before hospitalization.

Compared with the general adult population, older adults have a decreased physiological reserve and take longer to recover from illness. Apart from requiring more time for recovery, older adults need to return to a state of functional autonomy to reduce the incidence of subsequent disability, thus improving their quality of life and reducing the long-term burden on the care system. Previous research found that as many as 25%–35% of older adults lose at least one activity of daily living (ADL) following 10–14 days of hospitalization for acute illness,^1,2) 25% suffer cognitive functional decline after 10–14 days of hospitalization,^3,4) and 20%–25% experience emotional disturbances after discharge (chiefly depression and anxiety).^5,6) In addition, in 20%–40% of such patients, their nutritional status is worse than it was before hospitalization,⁷–⁹⁾ and all were at risk for falls after discharge.¹⁰⁾ However, the vast majority of patients discharged after acute care return home with no further care. A study showed that older adults who cannot recover their cognitive and physical function after hospitalization for an acute illness are at significantly greater risk of rehospitalization, disability, mortality, and placement in a long-term care facility; in addition, this places an increased care burden on family members.¹⁰⁾ The World Health Organization 2015 World Report on Aging and Health states that different medical systems will face different challenges as demographic aging increases the need for care. Despite the fact that developed countries have well-established medical systems, a fragmented care system has become a difficult-to-avoid phenomenon as a country’s population ages. The insufficient medical systems of developing countries are also struggling to respond to aging.¹¹⁾

This report reveals that the healthcare system as a whole still focuses on specialized care rather than a holistic return to health, provides chiefly fragmentary care, and commonly neglects providing care plans that enable functional recovery in older adults following treatment for acute illness. Consequently, in order to broadly enhance the quality of care for older adults and avoid a large increase in the disabled population due to aging, it is essential to construct a post-acute care service model for older people after hospitalization. The post-acute care model has been implemented in different countries for decades, but thus far, there is no consensus on an international definition. Several related terms need to be clearly distinguished, including transitional care, sub-acute care, post-acute care, and intermediate care. Transitional care broadly refers to the coordination and continuity of healthcare as patients transfer between different levels of care within the same location (such as acute illness to chronic illness or deconditioning status to permanent dependent status) or between different locations, including transfer between different hospitals, the patient’s home, primary and specialty care offices, long-term care facilities, sub-acute units, and post-acute units. The model of sub-acute care being conducted in the American healthcare system focuses on the extension of acute medical services beyond the period of acute instability by a non-acute care unit within or close to the hospital in order to shorten the length of acute inpatient care. Furthermore, the model of post-acute care in the American healthcare system is defined as providing integrated inpatient care directed at persons after their acute condition is stabilized by dealing with one or more specific, complex medical conditions in order to improve care quality and facilitate a return to the community. Meanwhile, the model of intermediate care in British healthcare systems is aimed at older people at home or in well-designed care facilities, in which medical and rehabilitation services are intended to promote autonomous living functions, reduce unnecessary hospitalization, ensure returning to home at an early date, and avoid unnecessary placement in a long-term care facility.

This paper therefore reviews the post-acute care development process, definitions, and care goals as well as the predominant post-acute care models in the United Kingdom (UK) and the United States (US). Lastly, this paper describes current post-acute care developments in Taiwan, assesses their effectiveness, proposes ideas for improving the post-acute care system in Taiwan, and provides some conclusions.

The development of post-acute care in the medical systems of various countries was originally motivated largely by the desire to reduce the length of acute care hospitalization and thereby lessen overall medical expenditures. Many countries consequently developed post-acute care models based on this consideration. For instance, the US began providing Medicare and Medicaid in 1965,^12,13) and the diagnosis-related group (DRG) concept was developed during the 1960s by Yale University scholars Fetter and Thompson¹⁴⁾ to promote disease management by classifying severity in diseases of the same type. DRG systems rely on the concept of “case grouping” to establish disease classification systems, and a DRG approach was adopted as a health insurance pricing standard when the US Congress passed the Medicare Prospective Payment System in 1983. However, because this approach allows uniform payments for different conditions, hospitals were encouraged to reduce acute medical expenditures and days of acute hospitalization and therefore had an incentive to discharge patients prematurely or refer them prematurely to other types of care.^15,16) As a result, the US began promoting sub-acute care during the 1980s. Sub-acute care, originally proposed to control the number of days of acute hospitalization, was also intended to meet patients’ care needs after discharge and chiefly relied on medical units or skilled nursing facilities (SNFs) near hospitals to provide care. Nevertheless, although sub-acute care was actively promoted to reduce acute medical expenditures, it failed to improve the quality of care as a whole. To enable patients with stable conditions to obtain early discharge and receive active post-acute care via a comprehensive care approach, the US 1997 Balanced Budget Act expanded the post-acute care services covered by Medicare, leading to the establishment of four key types of post-acute care units, namely SNFs, home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs), which covered inpatient, institutional, residential, and active rehabilitation care models. The American post-acute care case acceptance standards based on the post-acute care DRG systems led to significantly different groups of patients receiving care than under the intermediate care system of the UK.^17,18)

Although numerous studies have confirmed that aging will increase medical expenditures,¹⁹⁾ National Beds Inquiry report of the UK in 2000 found that, despite the continuous increase in the country’s older population starting in the 1980s, the number of acute hospital beds and days of patient hospitalization has in fact fallen steadily. The strict control of the number of days of hospitalization led to a very high percentage of older adults whose cognitive and physical function had not appropriately recovered being transferred to long-term care facilities. Because this system both decreased the health of the older adults and also burdened the country’s long-term care system, the UK was forced to establish a new integrated healthcare service model to provide care during the post-acute period to aid in the recovery of physical function. This model was termed the intermediate care system. The UK began developing intermediate care in 2001; it is currently considered one of the main reform programs of the British National Health Service and serves as an important basis for healthcare in the Department of Health and Social Care’s National Service Framework for Older People. Intermediate care has been the most important policy affecting care for older adults in the UK in recent years.

Intermediate care and post-acute care are both forms of transitional care for patients returning to the community after hospitalization for acute conditions, and both integrate community care resources to provide patients the needed healthcare services after they return home. Even though the American and British healthcare systems employ different assessment criteria and care service systems, intermediate care and post-acute care are based on the same concepts and, to avoid confusion, this paper will uniformly use post-acute care to refer to the care provided under both systems.

Despite the significant importance of post-acute care to older adults, there is no uniform international definition of post-acute care thus far, and this concept has been defined in different ways.

The optimal post-acute follow-up care setting for older adults depends on the individual patient’s treatment goals, and a single care setting is not necessarily the best choice. Because the chief goal of post-acute care is to promote independent living and avoid unnecessary hospitalization, a series of comprehensive care services is employed to help patients return home in the best possible state of health. Post-acute care services should therefore take “care close to home” as a principle and extend certain medical and social welfare services to the communities in which patients and their families live. Because patients’ needs span different organizations and services, multiple professional groups or organizations must take responsibility for post-acute care. The post-acute care setting should emphasize patient-centered care, integrate various kinds of service resources, and thereby seek to promote the greatest possible degree of cognitive and physical functional recovery. An additional important goal of post-acute care is to ensure that patients are not unnecessarily placed in a long-term care facility after hospital discharge. To achieve this goal and ensure patients can return to independent living, a physical reablement program must be arranged for patients before their return home.

Since the development of post-acute care, various settings and models have been introduced to achieve its goals.²⁴⁾ In the US, SNFs, HHAs, IRFs, and LTCHs have emerged to fill this need.²⁰⁾ In British post-acute care model, community hospitals, hospitals-at-home, nurse-led units, day hospitals, and social services all play roles.²⁵⁾ Service team models include rapid response teams, hospital supported discharge teams, community assessment and rehabilitation schemes, home rehabilitation teams, and stroke rehabilitation outreach teams.²⁵⁾

The following are some of the most commonly seen post-acute care service models in the UK and the US.

Although British studies have found that post-acute care can effectively reduce the rate of rehospitalization and placement in long-term care facilities, these studies made little mention of individual treatment results and the burden on caregivers.^30,37–³⁹⁾ Chen et al.⁴⁰⁾ found that post-acute care can indeed be effective in assisting patients’ functional recovery and can reduce 1-year mortality by as much as 62%. Post-acute care can effectively boost patients’ ADLs, instrumental ADLs, and cognition function, while reducing symptoms of pain and depression. Furthermore, Lee et al.⁴¹⁾ discovered a significant correlation between physical therapy and functional recovery during the post-acute care period, such that the more physical therapy the patient received, the better the functional recovery achieved, along with easing of pain and improvement in depression symptoms. Although sex, home living arrangement, and basic physical functioning are correlated with functional recovery, the most important factor influencing the effectiveness of post-acute care is the patient’s cognitive function.⁴²⁾

A 4-year longitudinal study of patients with hip fractures by Peng et al.⁴³⁾ found that if patients received in-home or community hospital post-acute care following surgery, motor function could be recovered within a short time and long-term mortality would drop significantly. Liu et al.⁴⁴⁾ found that, although 38% and 43% of patients in post-acute care units had symptoms of depression and anxiety, respectively, after integrated team treatment, symptoms of depression improved along with physical function, and the original symptoms of depression did not affect their prognosis.

When patients receive post-acute care services, unplanned rehospitalization occurs in 4%–35% of cases.⁴⁵⁾ Rehospitalization usually occurs in the first few days of post-acute care, and 89% of all cases are a result of infection, chronic obstructive pulmonary disease, acute heart attack, or heart failure.⁴⁶⁾ We found that only approximately 12.9% of the patients are transferred to the acute ward, which is better than the figures for many European and American countries, and the reason for hospitalization is usually infectious disease.⁴⁶⁾

Taiwan’s National Health Insurance began implementing post-acute care services for stroke patients in 2014. In the community hospital post-acute care model for stroke patients, personnel provide high-intensity rehabilitation training based on the patient’s Comprehensive Geriatric Assessment results, and patients are accepted based on the occurrence of stroke and a modified Rankin Scale Score of 2–4, indicating the patient’s functional status as determined by the acute hospital diagnosis. Interdisciplinary team-based post-acute care, which lasts up to 12 weeks, significantly improves patients’ physical functioning, cognitive function, mood, nutritional status, and neurological function, particularly balance.⁴⁷⁾ A study tracking patients discharged from the hospital to post-acute care found that patients continue to improve following discharge home and have lower rates of post-discharge emergency care and risk of rehospitalization within 90 days compared with those who did not receive post-acute care.⁴³⁾

Demographic aging has increased the number of older adults experiencing significant functional decline following acute medical care; if effective intervention for these short-term disabilities is not implemented, these patients are at greater risk of rehospitalization or placement in a long-term care facility, burdening the medical system, patients’ families, and society as a whole. In the midst of rapid aging and a trend toward smaller families, the establishment of a post-acute care service network will not only reduce medical expenditures and the burden on the long-term care system but can also help older adults effectively maintain self-care and their quality of life. How to integrate existing resources effectively to optimize post-acute care is consequently an important issue. Supported by the effectiveness of the stroke post-acute care provided since 2014, Taiwan’s National Health Insurance began implementing a number of post-acute care service programs in 2017, including programs for frail seniors and patients with heart failure, traumatic brain injury, and fragility fractures. It has also encouraged the establishment of various post-acute integrated care models, including an inpatient model, day care model, and home-based model. These models will enable older adults to receive optimal functional recovery care and maintain the best possible quality of life. Apart from its proven economic effectiveness, the evidence-based community home-based post-acute care models being implemented in Taiwan can also enable older individuals to receive rehabilitation at community health centers near their homes, or even at home. Because of this greater use of non-hospital resources, the implementation of the community hospital and home-based models of post-acute care will benefit all: the older people, their family members, the medical system, and the country as a whole.