Sir_Excellence

Unit 3: Week 3 - Chapter 5 Outline

CHAPTER FIVE: SUBACUTE AND POSTACUTE CARE

LEARNING OBJECTIVES

After completing this chapter, readers will be able to:

1.  Define and describe subacute and postacute care for the purpose of clarifying these confusing terms,

2.  Identify where subacute care fits in the continuum of care, the services it offers, and the consumers who use it.

3.  Identify sources of financing for subacute care.

4.  Identify and describe regulations affecting subacute care.

5.  Identify and discuss ethical issues affecting subacute care.

6.  Identify trends affecting subacute care into the near future and describe the impact of those trends.

CHAPTER HIGHLIGHTS

What is Postacute Care?

·         Services to patients needing additional support to assist them to recuperate following discharge from an acute hospital.

What is Subacute Care?

·         Comprehensive, cost-effective inpatient level of care for patients who have had an acute event.

What is the Difference between Postacute Care and Subacute Care?

Subacute Care                                                       Post-Acute Care

- May be either after or in place of acute care    - Is after acute care

- Provides in-patient services                               - Provides outpatient services

- Provides medical and nursing care                    - Provides nursing and/or

                                                                                 non-medical care

Postacute Care

·         Provided by:

·         Inpatient Rehabilitation Facilities

·         Long-Term Care Hospitals (LTCH)

·         Skilled Nursing Facilities

·         Home Health Agencies

·         Use of Postacute Care

·         About one-third of hospital patients go on to use postacute care. The most common, single, postacute care destination for beneficiaries discharged from acute inpatient care hospitals is a skilled nursing facility.

·         Medicare Conditions of Participation - providers must meet different conditions of participation

·         Bundled Payments - Like other Medicare-certified providers, post-acute care providers will be impacted by CMS’s Bundled Payments for Care Improvement initiative.

·         Readmissions - The Affordable Care Act of 2010 (ACA) reduces payments to hospitals for greater than expected readmissions, decreasing payments for all Medicare discharges in the prior year.

Subacute Care

How did Subacute Care come to be?

·         It is one of the fastest growing segments of the health care delivery system.

·         Result of pressures to be cost-effective, increased demand for consumer choice, and competition between providers.

Defining Subacute Care

·         Comprehensive inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process.

·         Goal oriented treatment rendered immediately after, or instead of, acute hospitalization to treat one or more specific active complex medical conditions or to administer one or more technically complex treatments.

Philosophy of Care

·         Specific care rendered for very specific reasons (conditions or treatments)

Ownership of Subacute Care Units

·         Often provided by existing hospitals or free-standing nursing facilities.

Services Provided

·         May include:

·         Rehabilitation

·         Physical and Occupational Therapy

·         Respiratory Therapy

·         Cardiac Rehabilitation

·         Speech Therapy

·         Postsurgical Care

·         Chemotherapy

·         Total Parenteral Nutrition

·         Dialysis

·         Pain Management

·         Complex Medical Care

·         Wound Management

·         Ventilation Care

·         Other Specialty Care

Care Planning

·         Involves assessing each individual patient's needs, developing a care plan to meet those needs, and constantly reviewing the care plan and adjusting it as needed.

Measuring Quality of Care

·         There are numerous excellent tools available for measuring outcomes-based effectiveness.

·         QAPI is the merger of two complementary approaches to quality, Quality Assurance (QA) and Performance Improvement (PI). Both involve seeking and using information, but they differ in key ways

Case Management

·         Its primary goal is the cost-effectiveness of the care given.

Consumers Served

·         Patients needing a high level of skilled care, generally with a defined treatment plan and timetable for discharge or transfer to another type of care.

·         They need rehabilitation, monitoring, or other specialized treatment.

Market Forces Impacting Subacute Care

·         Cost Saving Efforts – the primary impetus for subacute care.

·         Managed Care – A key promoter of subacute care.

·         Choice - The rising demand by health care consumers for more choice in their care is important.

Regulations

·         Subject to most of the same regulations as other providers, but is still an immature provider form.

Accreditation

·         Joint Commission – Joint Commission on Accreditation of Healthcare Organizations

·         CARF International – Commission on Accreditation of Rehabilitation Facilities

·         NCQA – National Committee on Quality Assurance

Financing Subacute Care

·         No single payer for subacute services, nor any standardized payment mechanism.

·         Most reimbursement comes from Medicare, Medicaid, and managed care organizations.

·         Managed care influence is growing, even for public payers.

Staffing/Human Resource Issues

·         Interdisciplinary team consisting of:

·         Program Administrator

·         Physicians

·         Nursing

·         Other Professional Staff

·         Non-Licensed Staff

· Recruitment

Legal/Ethical Issues

·         Fall into two general categories:

·         Meeting licensure and reimbursement regulations

·         Professional liability

Management

Management Qualifications

·         Subacute care administrators need the same skills as administrators of other health care organizations.

Management Challenges and Opportunities

·         Changing the Culture of the Organization – may be part of a hospital or skilled nursing facility with different culture

·         Balancing Cost and Quality – similar to other providers.

·         Coordination, Competition with Other Facilities, Organizations – need to work with others to survive.

·         Physical Facility Considerations – may have to adapt from another provider type.

Significant Trends and Their Impact on Subacute Care

·         Managed Care – a growing influence.

·         Changes in Acuity Levels – accepting patients from acute care – or instead of acute care presents certain problems.

·         Emphasis on Outcomes – more emphasis than other provider types since patients are there for specific treatments.

LECTURE OUTLINE

A.  Identify learning objectives for the session

B.  Introduce the lecture topic

C.  Discuss what subacute care and postacute care are, including:

1.     The difference between subacute care and postacute care

2.     The types of facilities that constitute postacute care:

·         Inpatient Rehabilitation Facilities

·         Long-Term Care Hospitals

3.     What subacute care is, plus how and why subacute care developed

D.  Philosophy of Care. Discuss the philosophy of care of subacute care, including the four categories of subacute care:

1.   Transitional

2.   General

3.   Chronic

4.   Long-Term Transitional

E.   Ownership. Identify who owns subacute care facilities or units

F.   Services. Discuss the services provided by subacute care

1. Rehabilitation

2. Physical therapy

3. Occupational therapy

4. Respiratory therapy

5. Cardiac rehabilitation

6. Speech therapy

7. Postsurgical care

8. Chemotherapy

9. Parenteral nutrition

10. Dialysis

11. Pain management

12. Complex medical treatments

13. Wound management

14. Ventilation care

G.  Discuss care planning and case management

H.  Consumers. Identify the consumers served

I.    Market Forces. Identify and discuss market forces impacting subacute care

1.   Cost saving efforts

2.   Managed care

3.   Choice

J.    Regulations. Discuss the regulations affecting subacute care, including:

1.   Medicare regulations

2.   OBRA regulations

3.   Other regulations

K.  Accreditation. Discuss accreditation, and how it applies to subacute care

      1.   Joint Commission

      2.   CARF

      3.   NCQA

L.   Financing. Discuss how subacute care is financed, and by whom

      1.   Medicare

      2.   Managed care

M.  Staffing/Human Resources. Identify and discuss staffing/human resource issues, including the interdisciplinary team made up of:

1.   Program Administrator

2.   Physicians

3.   Nursing

4.   Other professional staff

5.   Non-licensed staff

N.  Legal & Ethical Issues. Identify and discuss legal and ethical issues, including:

1.   Meeting regulations

2.   Liability

O.  Management. Discuss management of subacute care, including:

1.   Management qualifications

2.   Management challenges and opportunities

a.   Changing the culture of the organization

b.   Balancing cost and quality

c.   Coordination, competition with other facilities & organizations

d.   The physical facility

P.   Trends. Identify and discuss significant trends impacting subacute care, including:

1.   Managed care

2.   Changes in acuity levels

3.   Emphasis on outcomes

Q.  Summarize the discussion, recapping the key points of the lecture.

 

VOCABULARY TERMS:

Capitation - payment to health care providers on the basis of the number of people covered instead of payment for the services provided.

Care management - the process of developing and managing the care of a patient or resident, focusing on the quality of care delivered.

Care planning - the process of developing a plan of care for a patient or resident.

CARF International - an organization that accredits rehabilitation and human services providers.

Case management - the process of coordinating services received by a patient or resident; with a focus on cost-effectiveness.

Case manager - an individual who coordinates services received by a patient or resident; with a focus on cost-effectiveness.

Certificate of Need (CON) - a government program, begun in the 1960s, designed to limit the expansion of expenditures for health care building and renovation, by requiring prior approval of any such projects.

Chronic subacute care - these units care for patients with serious chronic conditions requiring services such as ventilator or intravenous therapy.

Continuous Quality Improvement (CQI) - a form of quality improvement adapted from Total Quality Management (TQM).

Diagnosis-Related groups (DRGs) - diagnostic categories used by Medicare as a basis for paying providers, who are reimbursed a fixed amount based on the DRG code

Gatekeeper - term used to describe the person or organization that directs a consumer to particular kinds/types of care.

General subacute care - relatively short-term subacute care for patients needing ongoing therapy or monitoring but who are not likely to need acute care.

Goal-oriented care - long-term care that is specially designed to achieve a specific goal, such as wound healing or rehabilitation (most often found in subacute care).

Interdisciplinary team - care team made up of representatives from several different professional specialties.

Joint Commission - an organization providing voluntary accreditation for health care providers.

Long-term transitional subacute care - subacute care for patients with more complex medical problems who need more intensive (but still not acute) care over a longer time before transitioning to home or another level of care.

Managed care organizations (MCOs) - systems that integrate the financing and delivery of health care by means of arrangements with a limited number of providers.

Medical subacute care - subacute care specializing in treating medical conditions as opposed to other forms of subacute care, such as physical rehabilitation.

National Committee on Quality Assurance (NCQA) - organization that accredits managed care organizations.

Quality Assurance &. Performance Improvement (QAPI) - a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. 

Rehabilitation subacute care - subacute care specializing in rehabilitation services such as physical therapy, occupational therapy, and speech therapy.

Skilled nursing facility (SNF) - a long-term care facility providing 24-hour nursing care and other related services.

Subacute care - comprehensive, goal-oriented care given following, or in place of, acute hospital care to treat a specific condition or to administer one or more technically complex treatments.

Transitional subacute care - usually quite short-term subacute care, serving as a means of transferring patients from highly-intensive, more expensive hospital units while maintaining the availability of acute care if needed.