The Continuum of Care The Pivotal Role of Post-Acute and Long-Term Care in Healthcare Delivery www.chanet.org For full citation information please see accompanying Issue Brief, “The Continuum of Care: The Pivotal Role of Post-Acute and Long-Term Care in Healthcare Delivery,” available at www.chanet.org. Many Hospitals. One Voice. 4/28/2017

The Continuum of Care Nation’s healthcare system traditionally defined by acute care The continuum of care spans a lifetime and includes: Preventive care Care management Acute care Post-acute care Long-term care For many, “healthcare delivery,” is not a moment in time but a series of events along a continuum. The continuum of care, as the concept is known, encompasses a comprehensive range of services to promote the health of an individual throughout the span of their lifetime. A broad range of services are provided along this continuum including preventive health services, care management, acute care, post-acute care, and long-term care.

Post-Acute Care Care provided to patients who are discharged from an acute-care setting but still require intensive medical treatment Typical Post-Acute Settings Long-Term Acute Care Hospital Skilled Nursing Facility Inpatient Rehabilitation Facility Post-acute care is one segment of the continuum of care and refers to care provided to patients who are discharged from an acute-care setting but who still require medical treatment. Post-acute care is typically provided in a Long-term acute care hospital, a skilled nursing facility or an inpatient rehabilitation facility.

Long-Term Acute Care Hospital (LTACH) Care for medically complex patients Average length of stay of 25 days Patients often transferred from ICU Typical services include Comprehensive rehabilitation Respiratory therapy Head trauma treatment Pain management Specialized respiratory care for patients requiring mechanical ventilation

Skilled Nursing Facility (SNF) Nursing home certified by the Centers for Medicare and Medicaid Services to provide skilled nursing services Aim is to restore patients to previous level of functioning SNF patients most often recovering from: Hip fracture Stroke Pneumonia Heart Failure

Inpatient Rehabilitation Facility (IRF) Post-acute option for patients who need intensive rehabilitation Patients must benefit from 3 hours of therapy everyday 60% of case mix must be patients with specific conditions including: Stroke Spinal cord injury Congenital deformity Amputation

Long-Term Care Assistance for those needing help with “activities of daily living” (ADLs) Serves the elderly as well as others Provided in Various Settings Home based Community based Assisted Living Nursing Facility Another segment of care along the continuum of care is long-term care. Like post-acute care, long-term care often serves individuals who are recuperating from a significant health event; however, any person who needs help with activities of daily living such as eating or bathing may receive long-term care services. Though many individuals receiving long-term care services are elderly, this is not always the case. Many people who are disabled, for example, need assistance with activities of daily living and rely on long-term care services for help. Close to half of the people receiving long-term care are under age 65. Long gone are the days when the only choice for long-term care was a nursing home. More than 10 million people receive long-term services in their own home from unpaid, informal caregivers such as friends and family. Paid services in the community or the home, such as home-health workers, meal delivery, transportation and homemaking services, are another alternative for those with long-term care needs. Assisted living is a group living arrangement in which residents have their own room or apartment within a facility and receive assistance with activities of daily living as needed. Nursing Facilities or nursing homes provide services to residents who are unable to be cared for in a home or community setting. Though the needs of residents are usually extensive, these facilities differ from SNFs in that residents do not require skilled nursing services. ________________________________________________________________________________________________________ •H. Stephen Kaye, Charlene Harrington, and Mitchell P. LaPlante, “Long-Term Care: Who Gets It, Who Provides It, Who Pays, and How Much?” Health Affairs 29, no. 1 (2010): 11-21. •Terrence Ng, Charlene Harrington, and Martin Kitchener, “Medicare and Medicaid in Long-Term Care,” Health Affairs 29, no.1 (2010): 22-28. •Medicare.gov, Long-Term Care, http://www.medicare.gov/LongTermCare/Static/Home.asp

Financing Care on the Continuum One year of nursing home care: $68,000 One year of periodic home health visits: $18,000 Payers of Post-Acute and Long-Term Care Individuals Insurance Medicare Medicaid There’s no way around it. Post-acute and long-term care are very expensive. Both require extensive resources and time. The U.S. Department of Health and Human Services estimates that one year of nursing home care costs around $68,000 while one year of visits from home health workers costs around $18,000. So, how do people pay for these services? The truth is, it depends on the type of care needed, the length of time the care is needed, the age of the patient and whether or not the individual has low income or assets. Sometimes, patients find the system so confusing, they opt to forgo care for fear that they will end up with bills that they cannot pay. ___________________________________________________________________________________________________________ •Terrence Ng, Charlene Harrington, & Martin Kitchener, “Medicare and Medicaid in Long-Term Care,” Health Affairs 29, no.1 (2010): 22-28.

Medicare Federal Program for those 65 and older Covers medical/rehabilitative care in various settings including: LTACH SNF IRF Does NOT cover long-term care Medicare, the federal program that provides health coverage to those age 65 and older, will pay for post-acute care after a hospitalization. It will cover the cost of this care in an LTACH, SNF or IRF. Medicare does NOT cover long-term custodial care such as that provided in a nursing facility for those with difficulties with activities of daily living. __________________________________________________________________________________________________________ •Centers for Medicare and Medicaid Services, “Medicare Coverage of Skilled Nursing Facility Care,” http://www.medicare.gov/Publications/Pubs/pdf/10153.pdf.

Medicaid Joint state and federal program Will pay for long-term care if: Individual is 65 or older Has low income and assets Individual of any age who has a major disabling condition Services can be provided: In a nursing facility At home Unlike Medicare, Medicaid will cover the cost of long-term care under certain circumstances. Those who are age 65 or older and who have low income and assets (and who haven’t intentionally impoverished themselves to qualify) are eligible. Those of any age with a major disabling condition, including mental illness, are eligible. Low income criteria for these services is set at 64% of poverty level in Ohio, or $6,656 per year for an individual. Medicaid will cover long-term care in a nursing facility or at home through a home and community-based service waiver. In Ohio, Medicaid pays for 47% of all nursing home care. ______________________________________________________________________________________________________________ •Health Policy Institute of Ohio, The. (2009). Ohio Medicaid Basics 2009, Columbus OH: Greg Moody.

Out-of-Pocket Post-Acute Care: Long-Term Care: Individuals may still pay premiums, deductibles and co-insurance associated with Medicare Medicare coverage for skilled nursing care runs out after 100 days Long-Term Care: 25% patients pay for care themselves Medicaid will pay once individuals spend down all of their assets paying for long-term care Another major payer for post-acute and long term care is the patient him/herself. Patients pay premiums, deductibles and co-insurance. They also must pay for any skilled care they receive after 100 days- the Medicare limit. Long-term care, in particular, is paid for by individuals themselves. Nearly one-quarter of long-term care is paid for out-of-pocket; however, as individuals spend down all of their assets paying for care, they then become eligible for Medicaid. Some individuals pay for care using private long-term care insurance. This is different than health insurance. Only 7 percent of Americans carry this kind of voluntary insurance. _____________________________________________________________________________________________________________ •Howard Gleckman, “Will Private Long-Term Care Insurance Supplement the CLASS Act?” Kaiser Health News, April 22, 2010. •MedPAC, “Skilled Nursing Facility Services Payment System,” Payment Basics, http://www.medpac.gov/documents/MedPAC_Payment_Basics_08_SNF.pdf (accessed April 1, 2010). •H. Stephen Kaye, Charlene Harrington, and Mitchell P. LaPlante, “Long-Term Care: Who Gets It, Who Provides It, Who Pays, and How Much?” Health Affairs 29, no. 1 (2010): 11-21.

LTACHs and Efficiency Relieve pressure on acute care ICUs and ERs Specialize in specific patient set Improve outcomes for certain patient groups Reduce re- hospitalizations The continuum of care, in which various care settings provide the highest level of expertise for a particular set of patients, promotes efficiency in the nation’s healthcare system. LTACHs, for instance, act as a pressure valve on hospital volume by allowing acute care hospitals to discharge stable but very sick patients, thereby creating room for new patients. This is crucial considering most instances of ambulance diversion result from too few beds in the critical care or intensive care units and the resulting inability to transfer patients out of the emergency room. LTACHs also increase efficiency by specializing in a very specific patient set- those who are very sick. Since LTACHs focus all of their efforts on this patient population, they know it well and tend to enjoy positive outcomes and favorable short-term survival, particularly for patients who are mechanically ventilated, or using a machine to help them breathe. Some research also points to higher efficiency in reduced re-hospitalizations. In fact, a study conducted for MedPAC, the independent Congressionally created agency charged with advising Congress on issues pertaining to Medicare, found that patients who were discharged to LTACHs were 26 percent less likely to be readmitted to the hospital than similar patients in other settings. _________________________________________________________________________________________________ •American Hospital Association, “State of the Hospitals Chart Pack,” 2007. •David J. Scheinhorn, et. al., “Post-ICU Mechanical Ventilation at 23 Long-Term Care Hospitals,” Chest 131, no. 1 (2007): 85-93. •MedPAC, “New Approaches in Medicare,” Report to Congress, June 2004, http://www.medpac.gov/publications%5Congressional_reports%5June04_ch5.pdf.

SNFs, Long-Term Care and Efficiency Skilled Nursing Facilities Specialize in rehabilitation Relieve pressure in acute care setting Ensure acute care treatment benefits are fully realized Reduce re- hospitalizations Long-Term Care Settings Provides help with daily living skills necessary for recovery Ensures medical regimens are followed Reduce re- hospitalizations Skilled nursing care enhances health system efficiency by promoting rehabilitative care. It is of obvious benefit to patients to restore functioning as much as possible. Skilled nursing facilities also allow acute care hospitals to discharge patients who still need a high level of care but may not require the degree of services provided in an acute care setting. As patients recover with the help of skilled care, they are also less likely to have to be admitted to the hospital a short time later for the same condition that put them there in the first place. Long-term care plays an important role in promoting efficiency, as well. Though it is not medical in nature, it does play a role in maintaining the health of those it serves. Help with activities of daily living and medical regimens like remembering to take medicine help prevent an individual’s health from deteriorating. This sort of help is essential for ensuring that these individuals are not rehospitalized.

Challenges along the Continuum Workforce shortages Highest vacancies for certain key workers Negative stereotyping of work environment Wages constrained by low Medicare & Medicaid Reimbursements Northeast Ohio provides plentiful opportunities for workers, increasing turnover & vacancy rates Workforce shortages are felt keenly in acute care as well as in post-acute and long-term care. Nurses are in short supply as are other key allied health workers such as physical therapists and occupational therapists. The highest vacancy rate in allied health in Northeast Ohio- at 26%- is for physical therapists and physical therapy assistants combined. Though this shortage is felt acutely throughout the healthcare system, skilled nursing care which focuses on rehabilitation is particularly affected. For years, post-acute and long-term care settings have also had a complicating factor in their attempt to recruit workers: negative stereotyping. This negative perception has discouraged potential workers from entering the field. At the same time, wages in long-term care are generally low because administrators are constrained by low Medicare and Medicaid Reimbursements. Intensifying the difficulty of hiring and keeping workers is the fact that workers in Northeast Ohio, a region defined by its robust healthcare sector, have a multitude of employment prospects. Put simply, if workers are unhappy, they have plenty of other options. ______________________________________________________________________________________________________________________ •The Center for Health Affairs, Northeast Ohio Nursing Initiative, “Allied Health: Supply and Demand,” http://www.chanet.org/NR/rdonlyres/E0C7E1C3-33A7-4463-B47C-D6D75D83C374/201/NEONI_SupplyandDemand.pdf (accessed May 5, 2010). •Robyn Stone and Mary H. Harahan, “Improving the Long-Term Care Workforce Serving Older Adults,” Health Affairs 29, no. 1 (2010): 109-115.

Challenges along the Continuum, Cont’d. Regulatory Environment 1 hour skilled care = ½ hour paperwork Resources diverted away from patient care LTACH 25-percent Threshold Rule Prohibits LTACHS from accepting more than 25% of patients from one hospital Adjusts reimbursement downward for all discharges Includes hospital-within-hospital LTACHs Many regulations are important because they keep patients safe while promoting the delivery of high-quality care; the sheer number of them can pose an administrative challenge for providers along the continuum. Some regulations actually have little to do with patient care and can even have the unintended consequence of diverting resources away from this primary objective. Take the 25-percent threshold rule, which applies to LTACHs. This rule states that if more than 25 percent of patients in an LTACH are admitted from any one acute care hospital during a set time period, then reimbursement will be adjusted downward for all discharges. The intent of this rule, promulgated by CMS, was to ensure that LTACHs were not functioning as units of an acute care hospital where long-stay patients were shifted simply to garner higher reimbursements. Certainly, policies that drive discharge location for purely financial reasons are not desirable, neither are policies that use arbitrary percentages to drive discharge location. Today, LTACH administrators must their admission decisions not only on the needs of the patient but also on whether they will be financially penalized for admitting them. ______________________________________________________________________________________________________________________ •Centers for Medicare and Medicaid Services, “Long-Term Care Hospital Prospective Payment System,” Payment Adjustment Policy Fact Sheet, http://www.cms.gov/MLNProducts/downloads/LTCHPaymentAdjustPolicy.pdf (accessed May 11, 2010).

Suggestions for Stakeholders Support quality patient care by advocating only policy changes that promote care, not those that merely add regulatory burden. Include representatives from post-acute and long-term care in policy discussions. Support policies to bolster the workforce. Develop strategies that ensure appropriate placement. Discourage negative perceptions through open and honest dialogue.