急性後期照護中最重要的是讓有功能進步潛能的個案，有機會經由復健團隊的介入，可以提早回到社區，減少入住照護機構。
　　社區復健是急性後期照護復健中重要的一環，包含醫療和長照資源的介入，如何在現有基礎進一步提升是非常重要。
　　在醫療部分，診所和地區醫院的復健團隊皆可提供一定量能的急性後期的社區復健，急性後期之醫療整合照護模式（Post-acute Care，以下稱PAC）中，有下面2種模式。急性後期整合照護「日間照護」模式：以「日間照護」門診全天方式提供上午及下午復健治療課程，時間以9點至17點為原則，提供個案的急性後期醫療照護。急性後期整合照護「居家」模式：經專業評估無法接受住院、日間照護模式的患者，但仍有積極復健潛能，提供有期限之居家復健治療。治療頻率由專業評定每週安排1-6次不等，時間30-50分鐘，運用簡易器材、就地取材、並透過家屬衛教方式，增進個案日常活動功能，及促進社區參與能力。
　　在長照部分，個案經由各縣市照管中心的照專，依多元評估量表評估個案長照需要等級（CMS），再交由A個管師與個案及家屬討論擬定照護計畫，依此照顧模式，民眾可以在社區復健依需求，在長照的A、B、C 三級單位中接受失能復健服務，並且可接受依「預防及延緩失能照護計畫」和「失智照護計畫」在不同單位所提供的創新長照 2.0，接受各類復健相關服務。醫院住院病人若評估出院有立即接受長照需求，可依「銜接長照 2.0 出院後準備友善醫院獎勵計畫」及 108 年度的「復能多元服務試辦計畫」，住院中完成評估出院可立刻接受服務。
　　The most important thing in post-acute care is to allow patients with the potential for functional improvement to have the opportunity to return to the community early through the intervention of the rehabilitation team, reducing the need to stay in care institutions.
　　Community rehabilitation is an important part of post-acute care rehabilitation, including the intervention of medical and long-term care resources. How to further improve the existing foundation is very important.
　　In the medical part, the rehabilitation teams of clinics and regional hospitals can provide a certain amount of energy in post-acute community rehabilitation.
　　In the post-acute medical integrated care model (Post-acute Care, PAC), there are the following two models . "Day Care" Model of Integrated Care in Post-Acute Stage: The "Day Care" outpatient clinic provides morning and afternoon rehabilitation courses throughout the day. The time is based on the principle of 9:00 to 17:00 to provide patients with post-acute medical care. Post-acute integrated care "home" model: After professional evaluation, patients who are unable to accept hospitalization and day care mode, but still have active rehabilitation potential, provide home rehabilitation treatment for a limited time. The frequency of treatment varies from 1 to 6 times per week according to professional assessment, and the duration is 30 to 50 minutes. The use of simple equipment, local materials, and family health education methods can enhance the daily activities of the cases and promote the ability to participate in the community.
　　In the long-term care part, the case is passed by the care center of each county and city, and the case is evaluated according to the multivariate assessment scale for long-term care needs (CMS). In the care model, people can receive disability rehabilitation services in community-based rehabilitation according to their needs, and receive disability rehabilitation services in long-term care A, B, and C 3-level units. This Plan provides innovative long-term care 2.0 in different units, and accepts various rehabilitation-related services. If the inpatients in the hospital are assessed to be in need of immediate long-term care after discharge, they can follow the "Connecting Long-term Care 2.0 Post-discharge Preparation Friendly Hospital Award Program" and the "Recovery Multi-Services Pilot Program" in 2018. After completing the assessment during hospitalization, they can be discharged from the hospital and receive service immediately.