What to Do When Elderly Seniors Become Ill and Need Hospitalization? The Post-Acute Care (PAC) Program for Frail Elderly Patients
Update Date：2026/01/05，
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Chief Nurse Jesca Chang and Discharge Planning Team, Director Huang Pin-Hsuan
Elderly seniors often require hospitalization due to illness. During their hospital stay, the lack of daily activities and extended bed rest can lead to a decline in physical strength and mobility, resulting in frailty. This can increase the burden on family caregivers.
I once took care of an 85-year-old patient, Mrs. Chen, who was admitted due to a lung infection and received antibiotic treatment. Before her hospitalization, she would attend activities at a community daycare center and lived independently, using a walker. Her two daughters took turns caring for her at home. However, during her hospitalization, she remained bedridden, and her daughters noticed that she seemed to have lost strength. They asked, "Since my mother has become noticeably weaker after being hospitalized and refuses to get out of bed, how will she manage when she goes home after discharge?"
In the past, after acute treatment, patients who did not immediately receive proper rehabilitation training often faced functional decline, increased caregiving burden, and even a higher risk of re-hospitalization. To address this, the government launched the Post-Acute Care (PAC) program to provide a continuous rehabilitation service between "acute medical care" and "subsequent care." The PAC program focuses on the first three months, the "golden rehabilitation period" after a specific illness, offering sustained, intensive, and integrated rehabilitation training. This significantly increases the chances of patients regaining their previous level of functioning. The core idea of PAC is "seizing the early phase, integrating rehabilitation, and returning to life." Through PAC, the cycle of "hospitalization – decline – re-hospitalization" that many elderly patients often experience can be effectively avoided, allowing patients to truly recover and return to their families and communities.
The PAC program currently targets conditions such as stroke, burn injuries, traumatic nerve damage, fragile fractures, frailty in the elderly, and heart failure. The care methods vary depending on the condition, and the frail elderly PAC can be divided into inpatient and home care models, specifically for elderly patients aged 75 and above.
Inpatient PAC for Frail Elderly: Process
1. Evaluation after Acute Medical Stabilization: Within 30 days of the disease treatment, the attending physician, along with geriatric and rehabilitation specialists, will assess whether the patient is suitable for PAC.
2. Referral: If the patient qualifies, the discharge planning case manager will discuss the referral to a PAC-certified hospital with the family.
3. Intensive Rehabilitation: Over 2-3 weeks, the patient will undergo intensive rehabilitation, which includes physical therapy, occupational therapy, speech therapy, and swallowing training. In inpatient care, hospitals also provide nursing care, nutritional support, and social work services.
4. Transition to Community Care: After the program ends, the patient is discharged and referred back to community care services.
Home PAC Model:
Elderly patients who are unwilling to transfer to a PAC facility after hospitalization can opt for the "home PAC" model. This model is designed for patients who cannot be admitted to the hospital or participate in daytime care but still have potential for active rehabilitation. Before discharge, the discharge planning case manager refers the patient to a team that provides home-based PAC. A professional rehabilitation team (e.g., physical, occupational, and speech therapists) will visit the patient's home to provide time-limited home rehabilitation therapy. The frequency of visits will depend on the assessment, ranging from 1 to 6 visits per week, each lasting 30-50 minutes. Simple equipment is used, and caregivers are educated to help improve the patient's functionality and reintegrate them into community life. This is one of the seamless post-discharge options in the PAC program. After the program ends, community long-term care resources (e.g., home medical care, long-term care services, family doctor plans) will be linked.
Conclusion:
Post-Acute Care (PAC) provides a structured, continuous, and individualized rehabilitation system to help patients achieve the best rehabilitation outcomes during the golden recovery period, reduce functional decline, and accelerate their return to daily life. In the rapidly aging society of Taiwan, PAC not only improves the health of elderly patients but also reduces overall medical and care costs, making it of great importance to families and society. If you or your elderly family member is in the recovery phase after an acute illness, feel free to discuss with your attending physician, rehabilitation team, or our case managers about participating in the PAC program to make the recovery process more directed and efficient while alleviating the burden on caregivers.