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American Heart Association/American Stroke Association Recommends
That Patients Who Have Strokes Receive Rehabilitation at Inpatient Rehabilitation Hospitals, not Skilled Nursing Facilities

For the first time, the American Heart Association/American Stroke Association has issued a Scientific Statement and guidelines strongly recommending that, “whenever possible,” “stroke patients be treated at an in-patient rehabilitation hospital (now often referred to as Inpatient Rehab Facilities – IRF’s) rather than being treated at a skilled nursing facility.”[1]  The association recognizes the importance of intensive, multidisciplinary treatment that only inpatient rehabilitation hospitals provide.

The Statement and guidelines encourage families to advocate for an inpatient rehabilitation facility for their family members who have had strokes and, in a recommendation that they recognize will “probably change medical practice,” to insist that stroke survivors “not be discharged from the hospital until they have participated in a structured program on preventing falls.”  Such a program “includes education about changes to make the home safer (such as removing throw rugs and improving lighting), minimizing the falls risk resulting from the side effects of medication, and safely using assistive devices such as wheelchairs, walkers and canes.” 

The new guidelines are discussed in detail.[2]

The Medicare Payment Advisory Commission (MedPAC), a nonpartisan agency that advises Congress on Medicare policy, supports the principle of site-neutral payments (“Site-neutral payments stem from the Commission’s position that the program should not pay more for care

in one setting than in another if the care can be safely and efficiently (that is, at low cost and with high quality) provided in a lower cost setting.”[3]).  In June 2014, MedPAC devoted a chapter of its report to Congress to site-neutral payments for inpatient rehabilitation hospitals and skilled nursing facilities.[4]  MedPAC analyzed rehabilitation following stroke as one of three care areas where the principle of site-neutral payment could be applied.  MedPAC found many differences among stroke patients and concluded that more work needed to be done to determine which stroke patients need care in an inpatient rehabilitation hospital, although it supports continued analysis of site-neutral payments.[5]

The American Heart Association/American Stroke Association recommends that stroke patients receive their post-stroke rehabilitation in skilled nursing facilities only if there is “good reason” not to go to an inpatient rehabilitation hospital, such as being “medically unable to participate” in inpatient rehabilitation hospitals’ intensive therapy program.[6]

The Center for Medicare Advocacy opposes site-neutral payments in these two settings and supports maintaining the level of care that inpatient rehabilitation hospitals provide.[7]

May 17, 2016 – T. Edelman

[1] AHA/ASA Newsroom, “In-patient rehab recommended over nursing homes for stroke rehab” (News Release, May 4, 2016).
[2] Carolee J. Winstein, et al., “Guidelines for Adult Stroke Rehabilitation and Recovery; A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association,” Stroke (May 2016), published online before print, May 4, 2016,  An Abstract of the Guidelines is available at
[3] MedPAC, Report to the Congress: Medicare and the Health Care Delivery System, chapter 6, Site-neutral payments for select conditions treated in inpatient rehabilitation facilities and skilled nursing facilities, page 97 (June 2014),
[4] Id.
[5] Id. 119.
[6] American Heart Association/American Stroke Association, “In-patient rehab recommended over nursing homes for stroke rehab,” page 1 (News Release, May 4, 2016),
[7] Center for Medicare Advocacy, “No Site Neutral Payments for Inpatient Rehabilitation Facilities and Skilled Nursing Facilities” (Alert, Dec. 14, 2014),

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