13 Things to Know About Sub Acute Rehab (SAR)

Questions and Answers About Subacute Rehabilitation

Sub acute rehab (also called subacute rehabilitation or SAR) is complete inpatient care for someone suffering from an illness or injury. SAR is time-limited with the express purpose of improving functioning and discharging home.

SAR is typically provided in a licensed skilled nursing facilty (SNF). Sometimes, SNFs are part of a hospital system and even physically located on the same campus, while other times, they're independent organizations. Regardless, a SNF must be licensed by the Centers for Medicare and Medicaid (CMS) in order to provide SAR. This licensing process includes regular onsite surveys to verify compliance with regulatory health requirements and life safety codes (such as fire protection and exit strategies).

1
Who Pays for SAR?

Medicare Sometimes Pays for SAR
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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.

2
What Services Does a SAR Center Provide?

Man Receiving Sub Acute Rehab
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SAR provides help in two different areas:

  1. 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, work to 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, and more.
  2. Licensed nursing staff provide medical care such as wound management, pain management, respiratory care, and other nursing services that must be provided or supervised by a licensed RN or LPN.

3
Who Might Benefit from a Stay at SAR?

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

Common conditions of people receiving SAR include 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 chord injuries, amputation and more.

4
How Much Therapy Does SAR Provide Each Day?

Man Receiving Subacute Rehab
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Your doctor will typically order therapy for you based on the recommendation of the physical therapist, occupational therapist, and/or speech therapist. Some people can only tolerate 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 3 hours of therapy per day.

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

5
How Long Do People Stay at an SAR?

Length of Stay at Sub Acute Rehab
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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 an SAR facility, including the extent of your injuries or medical condition, your overall health, how long your insurance approves for you to stay and your ability to live safely after you leave the SAR.

6
What's the Difference Between SAR, Acute Rehab and a Hospital Stay?

Hospital/Acute Care
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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 more than 3 hours a day of physical, occupation, or speech therapy.

Sub acute rehab (SAR) centers are usually most appropriate for persons who need less than 3 hours of therapy a day, thus the label of "sub acute," which technically means under or less than, acute rehab.

7
How Can I Find a High Quality SAR?

Woman Researching Nursing Homes Online
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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 the interactions of the staff with the patients 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.

8
Can I Choose Any SAR Facility I Want?

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. And, 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.

9
What If I Want to Leave SAR Before They Say I'm Ready?

If you're just itching to go home before the medical staff think you should, you do have the right to leave the facility at any time. If the physician 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 a protective form for the facility because without documentation that your discharge home was against medical advice, they could otherwise be liable for harm that occurred due to your early discharge.

An exception to this rule is that if you have dementia to the extent that your power of attorney for healthcare has been activated, this person must be the one who signs you out of a facility.

10
Why Is My Insurance Stopping My Coverage at SAR?

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 has 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 that you no longer require skilled therapy or skilled nursing services, that you're not able to participate in the therapy services (for example, if you have dementia and your memory is impaired, you might not be able to remember and learn new instructions very well), that you continuously choose not to participate in therapy services or that you've used up your allotted number of days for SAR.

11
What Can I Do if I Don't Think I'm Ready to Go Home Yet?

Senior Man Talking to Doctor about His Concerns
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After being told that the insurance coverage is ending for your SAR stay, many people 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.

12
What If SAR Doesn't Help Me Become Safe Enough to Go Home?

Caregiver Talking and Comforting Older Woman
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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, as 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.

13
What If I Still Need Help at Home?

Home Health Care Nurse Giving a Shot
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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 are trying 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 your rehab progress there.

Before you are 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 health care 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.

A Word from Verywell

Knowing what you can expect from SAR can help you make the most of the services provided there and return safely home. We understand that you may have many questions as you go, and our hope is that this guide can help you along the way through a variety of different scenarios.

Sources:

Medicare.gov. Skilled nursing facility (SNF) care. https://www.medicare.gov/coverage/skilled-nursing-facility-care.html

Sheltering Arms Physical Rehabilitation Center. Acute vs. Sub-Acute. http://www.shelteringarms.com/sa/acutecareinfo.aspx

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