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Overwhelmed Hospitals May Soon Lead to Overwhelmed Rehabilitation Facilities Unless Post–Acute Care Infrastructure Is Strengthened

Marwaha, Jayson S. MD; Terzic, Carmen M. MD, PhD; Kennedy, David J. MD; Halamka, John MD, MS; Brat, Gabriel A. MD, MPH

Author Information
American Journal of Physical Medicine & Rehabilitation: May 2021 - Volume 100 - Issue 5 - p 441-442
doi: 10.1097/PHM.0000000000001737
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To the Editor:

The United States is in the throes of its worst wave of COVID-19 yet.1 Among many of the problems that arose from an overwhelmed healthcare system during the first wave in early 2020, one was a severe shortage of rehabilitation beds.2–5 During that first wave, anecdotes abounded of overpacked and understaffed skilled nursing facilities and long-term acute care hospitals6–8; hordes of discharged COVID-19 patients with extensive rehabilitation needs did not have anywhere to go.

Hospitals are once again being overwhelmed with inpatients, many of whom may go on to overwhelm long-term acute care hospitals, inpatient rehabilitation wards, skilled nursing facilities, and other aspects of our rehabilitation system yet again unless capacity is quickly increased. Nationwide concurrent COVID-19 hospitalizations at the peak of the first wave were about 60,000 in April 2020.9 More recently, in early 2021, the number of concurrent COVID-19 hospitalizations rose to over two times higher at 130,000—and more hospitalizations will likely lead to more discharges to rehabilitation. Many large academic rehabilitation centers have already started to feel this pressure. At one large academic long-term acute care hospital that the authors are affiliated with, the COVID-19 patient census has tripled from October 2020 to January 2021. While national-level data on rehabilitation bed occupancy are lacking, this single-institution experience highlights a common trend across the country of soon-to-be-overwhelmed rehabilitation facilities and a need to build capacity quickly.

During the first wave of the pandemic in the United States, increasing intensive care unit (ICU) and hospital bed capacity was a universal priority: makeshift field hospitals and tents were set up to cope with the demand. In many cases, rehabilitation beds were converted to acute care beds as well.3,10 In fact, some rehabilitation facilities were entirely repurposed to serve as COVID-19 acute care hospitals.11 This left little postdischarge capacity for rehabilitation. To worsen the shortage, there was also significant demand for beds for patients with extensive rehabilitation needs for non-COVID-19 conditions like strokes and trauma. As a result of the shortage, there is anecdotal evidence that access to care for rehabilitation patients with both COVID-19-related and -unrelated conditions may have deteriorated.6–8

But why do coronavirus patients have such extensive rehabilitation needs, even after they have fought off the infection? As research and the past several months have shown, COVID-19 can leave survivors with profound neurologic, psychiatric, pulmonary, and cardiac disabilities. Treatments for severe infection further compound their rehabilitation needs: many COVID-19 patients who have been deeply sedated, chemically paralyzed, ventilated, and anticoagulated for long periods of time have had strokes or woken up with the inability to swallow or speak.12,13

To meet these patients’ postdischarge care needs, two key strategies used to build ICU capacity across the country must be translated to build rehabilitation capacity. The first is to consider designating COVID-19-only rehabilitation facilities, in the same way many hospitals were designated to provide COVID-19-only care. This will help limit COVID-19 exposure to frail non-COVID-19 rehabilitation patients who are there for other reasons. It will also consolidate COVID-19 post–acute care in one location, thereby possibly improving efficiency and wasting fewer resources caring for a mix of COVID-19 and non-COVID-19 patients.

The second translatable lesson is improved data transparency. Throughout the pandemic, ICU bed occupancy and availability have been very closely monitored. The US Department of Health and Human Services requires daily reporting of personal protective equipment supply and ICU bed availability by hospitals to state departments of health, and for these departments to report state totals to the federal government daily.1,14 Albeit an imperfect process, these data have enabled resources like personal protective equipment to be prioritized for certain regions based on need, funding to be allocated for new ICU beds, and reallocation of sick patients to facilities with excess capacity. To solve the impending rehabilitation crisis, that same level of visibility is needed over rehabilitation beds. Similar to acute care hospitals, a reporting system to account for bed availability across rehabilitation facilities at both the state and federal level should be implemented. Data on the post–acute care trajectory of these patients—what resources they need and how long they need care for—must also be collected and shared. Increased data transparency across health systems will enable funding to be prioritized for capacity-building in hard-hit areas and may help redistribute rehabilitation patients from overburdened facilities to places with excess capacity. The benefits of this approach extend beyond just rehabilitation facilities: better collection and sharing of data from outpatient rehabilitation encounters may enable a better understanding of the trajectory of COVID-19 “long-haulers” (patients who continue to have subacute symptoms many months after clearance of infection) as well.13

In May 2020, several post–acute care facilities in Boston banded together to do just this—share bed and equipment availability statistics with each other to redistribute resources appropriately.4 The United States is not destined to suffer the same aftershock of this wave as it did after the first wave in early 2020. With strategic planning and cross-institutional collaboration like this—but on a larger scale—a second rehabilitation bed crisis may be avoidable.

Jayson S. Marwaha, MD
Department of Biomedical Informatics
Harvard Medical School
and Department of Surgery
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Carmen M. Terzic, MD, PhD
Department of Physical Medicine
and Rehabilitation Mayo Clinic Rochester, Minnesota
David J. Kennedy, MD
Department of Physical Medicine and Rehabilitation Vanderbilt University Medical Center Nashville, Tennessee
John Halamka, MD, MS
Mayo Clinic Platform Mayo Clinic
Rochester, Minnesota
Gabriel A. Brat, MD, MPH
Department of Biomedical Informatics Harvard Medical School and Department of Surgery
Beth Israel Deaconess Medical Center Boston, Massachusetts


The authors would like to thank Brian C. Drolet, MD, FACS, of Vanderbilt University Medical Center and Harlan M. Krumholz, MD, SM, of the Yale School of Medicine for their feedback on this article and insights on this topic.


1. Leatherby L, Keefe J, Tompkins L, et al.: ‘There’s no place for them to go’: I.C.U. beds near capacity across U.S. The New York Times. December 9, 2020. Available at: Accessed December 19, 2020
2. Opinion | Covid-19 survivors need care. That’s the next challenge. The New York Times. Available at: Accessed December 19, 2020
3. Makam AM, Grabowski DC: How can we ramp up hospital capacity to handle the surge of COVID-19 patients? Long-term acute care hospitals can play a critical role. Health Affairs. April 13, 2020. Available at: Accessed December 19, 2020
4. Moore D: COVID-19 patients are recovering, but with nowhere to go. The Boston Globe. Updated May 19, 2020. Available at: Accessed December 19, 2020
5. Fiore K: Back into the lion’s den: COVID-19 and post–acute care. Medpage Today. July 16, 2020. Available at: Accessed December 19, 2020
6. Silver-Greenberg J, Abrams R: Nursing homes oust unwanted patients with claims of psychosis. The New York Times. September 19, 2020. Available at: Accessed December 19, 2020
7. Silver-Greenberg J, Harris AJ: ‘They just dumped him like trash’: Nursing homes evict vulnerable residents. The New York Times. June 21, 2020. Updated July 23, 2020. Available at: Accessed December 19, 2020
8. Graham J: Coronavirus patients caught in conflict between hospital and nursing homes. Kaiser Health News. March 30, 2020. Available at: Accessed January 21, 2021
9. US currently hospitalized. The COVID Tracking Project. Available at: Accessed January 24, 2021
10. Gurwitz JH: COVID-19, post–acute care preparedness and nursing homes: Flawed policy in the fog of war. J Am Geriatr Soc 2020;68:1124–5
11. Robbins A, Beilman GJ, Amdahl B, et al.: Transforming a long-term acute care hospital into a COVID-19–designated hospital. Surg Infect (Larchmt) 2020;21:729–31
12. Belluck P: Coronavirus survivors: Here’s what recovery may look like. The New York Times. July 1, 2020. Available at: Accessed December 19, 2020
13. Marshall M: The lasting misery of coronavirus long-haulers. Nature 2020;585:339–41
14. Piller C: Federal system for tracking hospital beds and COVID-19 patients provides questionable data [published online ahead of print November 29, 2020]. Science. doi:10.1126/science.abf8461
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