By Melinda Young

The continuum of care hit roadblocks in some U.S. cities as the COVID-19 pandemic made post-acute care transitions extremely challenging.

In New York City, the epicenter of the pandemic in March and April 2020, case managers needed to transition patients from acute care beds quickly, but had to adjust to surge obstacles to their usual post-acute options, according to the results of a recent study.1

In late March 2020, Montefiore Health System of Bronx, NY, increased its bed capacity by up to 150% in anticipation of receiving a surge of COVID-19 patients. This affected care transitions with its partners, an inpatient rehabilitation hospital and a skilled nursing facility.1

The health system had multiple options for transitioning patients to post-acute care facilities before the pandemic, says Sheryl R. Levin, MD, clinical director of rehabilitation consultation and post-acute care in the department of rehabilitation medicine at Montefiore Medical Center.

“What happened during the surge — and it’s happening to some extent now — is our rehab in the Bronx was closed,” Levin says. “There was limited availability for rehab, and we were not able to send patients out of our system because other systems were struggling, too.”

Maintaining adequate stores of personal protective equipment (PPE) and other supplies also was challenging in both acute and post-acute care settings, including home care services. Subacute organizations also struggled with adequate staffing because many of their employees were sick with COVID-19.

Limited Options for Transitions

This early tactic evolved into a more efficient process of transitioning severe, recovering COVID-19 patients with rehabilitation needs to the inpatient rehab setting, and keeping medical patients with COVID-19 at the acute care hospital until they stabilized.1

“Usually, you could offer patients choices, but we didn’t have those choices available to us,” Levin says. “We had very little bed availability for acute rehab, and we also had to worry about PPE [and] how much oxygen a patient was on.”

If patients were ready for discharge, but COVID-19-positive, the question was whether they could be sent home, where other members of the family might not be able to provide adequate care. Home care was limited, she adds.

Some medically stable patients were transitioned to an acute, inpatient rehab hospital in the health system, but this facility remained full, limiting it as an option. “We needed beds, but where would we send them because our partners for subacute rehab could not accommodate the patients, and [the acute care rehab hospital] also remained full,” she explains.

Inpatient rehab can provide a higher level of medical care and supervision. They can help acute care hospitals with bed availability by accepting patients who are stable enough for acute care discharge, but are not ready to be transitioned home. But many of these facilities were temporarily suspended during the COVID-19 surge because their beds were needed for medical/surgical patients.2

In turn, case managers and facilities were creative with care transitions. “Part of our surge plan was to take patients, who were not ready to go home and could not transition yet to rehab, and put them in the conference center, a transitional area, where they could receive medical care,” Levin says.

Regulatory and rule changes helped facilitate transitions of care during the pandemic. For example, some insurance companies lifted authorization requirements. This meant patients could be moved as needed.

One of the most important ways they facilitated better transitions during the surge was through improved internal communication. “We have fabulous case managers here. For me, the greatest lesson was communication, relying on each other’s strengths, and talking about it early on in the patient’s care,” Levin says. “We’re so much better at [transitions] now with social work case managers, the medical team, and acute rehab.”

They also worked with home care organizations to set up oxygen-weaning protocols in the community and establish therapy expectations. “We developed an intensive rehab option, where home care might not have nursing staffing, so we could send in a good therapist to provide patient support almost daily,” Levin says.

This helped patients who would have been sent to a subacute facility. “This was a way to help us free up acute care beds and to get patients to appropriate discharges. It was all about communication with case managers and the rehab team and pulling together as teams to work together intensely,” Levin says. “We instituted physician-to-physician discussions, and case management was very involved. Physicians talked with each other and updated each other about expectations for rehab, outcomes, and prioritizing patients, according to who could best benefit from acute inpatient rehab and from subacute care.”

Restructuring the Process

Before the COVID-19 crisis, the care transition pathway involved nine steps, including insurance verification, patient/family facility choice, facility referral, and insurance authorization. During the crisis, those steps were eliminated, and the transition pathway moved from patient consent to one of two options: direct physician-to-physician discussion for immediate acceptance and an inpatient rehab transfer when the patient was medically ready, or a facility admission screen and acceptance, followed by a skilled nursing facility transfer when the patient was medically ready.1 “Our processes are better streamlined than before,” Levin says.

By late summer and fall, the care transition process returned to a more normal course, but some resurgence occurred in late 2020. “We worked seven days a week until the middle of July,” Levin says. “We’re definitely not inundated the way we were before. The [COVID-19] long-haulers here are people with chronic symptoms, and they may not need inpatient rehab.”

The health system began a post-COVID-19 program, where people go home and receive follow-up care for chronic issues. Other COVID-19 patients, including people who had a stroke, respiratory failure from pneumonia, or those who underwent an amputation because of COVID-19 blood clots, are more debilitated and require acute rehabilitation.

“There are problems like that, which are really devastating,” Levin says.


  1. Levin SR, Gitkind AI, Bartels MN. Effect of the COVID-19 pandemic on postacute care decision making. Arch Phys Med Rehabil 2021;102:323-330.
  2. Gitkind AI, Levin S, Dohle C, et al. Redefining pathways into acute rehabilitation during the COVID-19 crisis. PM R 2020;12:837-841.