The Black Hole: Post Acute Care Laura Gorman, RN One Call Care Management

At the end of this session the participant will be able to: Post Acute Care: Objectives: At the end of this session the participant will be able to: List the various post acute facilities Describe the type of patient served in these facilities Discuss the admission criteria and process Recognize the differences in post acute facilities vs acute care

Post Acute Care offers many options Outline: Various post acute facilities Define each type of facility Criteria for admission and discharge from each level of care Expectations for type of care and outcome Types of providers

Diagnostics including Acute Care (the SUN) Administration Diagnostics including Radiology MRI CT Nuclear med Cardiac cath lab Cardiac testing Pulmonary functions testing

Critical Care Services Emergency Department Critical Care Services CCU SICU PICU NICU Maternal/Child Health OB/GYN Nursery Pediatrics Medical-Surgical Services Transplant Services

Therapy (in and out patient) Social services/Discharge planning Chaplaincy Surgical services Endoscopy Invasive procedures Recovery room Anesthesia

Dietary and nutritional services Human resources and training Admissions Medical Records Finance Information Technology and Communication Maintenance Security Housekeeping

Pharmacy Patient Education Laboratory Chemistry Microbiology Pathology Morgue Blood Bank

Costs in Acute Care The preceding slides list the usual departments within most Acute Care Facilities There may be more for teaching hospitals, regional trauma centers and specialties such as transplant centers, etc… All of these services are integral to an acute care facility offering many services to various levels of care including both in and out patient All of these services drive the overhead for these facilities and this cost is distributed among patients as part of the fee for their bed These services or at least the wide variety and the on site lab, diagnostics, etc… are often NOT needed for patients able to be appropriately served in a post acute setting.

Costs in Acute Care (continued) For example: surgical services are very expensive and essential in a hospital. Many patients in a hospital use these services at least once if not more often during their stay. A patient needing rehab or complex wound care won’t need these services urgently and certainly won’t require these services on site. Because of this the cost per day for a bed in a post acute facility such as skilled nursing can be lower reflecting the level of acuity meaning the patients are more stable medically. As well the costs reflect the lower overhead as these facilities provide appropriate care without the high costs of departments not needed and/or the lower cost of services that are used in a smaller setting.

LTACH (Long term acute care hospital) This is considered a specialty care hospital designed for patients with serious medical conditions which will necessitate intense treatment for a prolonged period of time. Conditions which may qualify for LTACH Ventilator weaning with a tracheostomy Wound care Stroke recovery and therapy IV therapy (antibiotics, hyperalimentation, etc…) Hemodialysis Other conditions requiring critical oversight

Characteristics of a LTACH patient Average length of stay is 25 days or longer LTACH patient would have primary or respiratory complexity that requires daily intervention by a physician, nurse practitioner or physician assistant daily. These facilities are often part of a larger medical facility or they may be a free standing facility often part of a chain specializing in this type of care. These facilities function independently and are licensed on their own.

Benefits of LTACH These facilities are able to focus on a limited number of specialized treatments and procedures so they can minimize their overhead making them able to be more cost effective even with these complex cases. These are often patients discharged directly from an ICU but unable to be cared for in a rehab facility or skilled nursing setting.

Process for Admission These facilities screen their patients to assure they have a payer source and are able to be cared for appropriately. This process will often take a few days or longer as the receiving facility will review insurance or payment often requiring authorization. As well there is a review of medical records, potential discharge plan and family/social/behavioral issues.

LTACH features For those facilities within a larger medical center there is access to services such an diagnostics, operating or procedure suites but they are often in an adjacent building A free standing LTACH will often have a portable x-ray and some limited laboratory capabilities but they do not have many of the services offered in an acute care hospital.

In Patient Acute Rehabilitation (physical) This facility is appropriate for the patient who will benefit from an intensive multidisciplinary rehabilitation program. Amputee Brain Injury Cardiopulmonary Rehabilitation Neurological Rehabilitation Spinal Cord Injury Stroke

Requirements Must have a pre admission assessment done by the facility within 48 hours of admission Must require active and ongoing intervention Minimum of three hours of therapy/day, (15 hours/7 day period) Standard is 1:1 therapy, can be group but not majority Show measurable improvement Family/patient conference weekly Individualized Overall Plan of Care must be documented

Skilled Nursing Facility Primary payer source for these facilities Medicare and Medicaid Processes and compliance are set up around these payers Licensure by the state and reported to CMS

Skilled nursing facility will provide services at a much reduced cost compared to hospital, LTACH and In Patient Rehab Facility Patient is screened prior to admission to assure medical services are able to be provided appropriately Payer source is verified and accompanying paperwork is completed Work closely with discharge planner at hospital

Patient must require “skilled services” General definition: A skilled nursing service is a service that must be provided by a registered or licensed practical nurse under the supervision of a registered nurse to be safe and effective. Various other skilled services such as physical, occupational and speech-language therapy.

Nine services as defined by Medicare IV or IM injections or IV feeding Enteral feeding (tube feeding) that compromises at least 26% of daily calorie requirements and 501 cc of fluid Nasopharyngeal or tracheostomy aspiration Insertion and sterile irrigation and replacement of suprapubic catheters Applications of dressings involving prescription medications and aseptic technique

Initial phases of a regimen involved administration of medical gases continued Treatment of extensive decubitus ulcers or other widespread skin disorder Heat treatments which have been specifically ordered by physician as part of active treatment and which require observation by nurses to adequately evaluate the patient’s progress Initial phases of a regimen involved administration of medical gases Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing that are part of active treatment.

Skilled Nursing These facilities do NOT have the overhead of a hospital but the patients should be stable enough not to need those services on site. These facilities DO offer nursing, therapy, dietary and social services. As well they have access to x-ray, lab and pharmacy services.

Often done under Skilled Nursing License Sub Acute Care May provide services for rehab patients who may not yet be able to do three hours of therapy May provide services for patients who are no longer requiring acute medical care but still need oversight for complex medical conditions Often done under Skilled Nursing License

Assisted Living Facility Assisted Living Housing is an option that provides personal care support such as meals, medication management, bathing, dressing and transportation. It does NOT offer skilled care It is a less expensive, residential approach delivering many services often by home health agencies or personal care staff.

These facilities are also licensed by the state and surveyed routinely. It is not the same as a nursing home as these individuals are typically mobile and able to provide some self care. These facilities are typically “rented” on a monthly basis requiring deposits.

Case Management Case management is often the thread that holds the case together throughout this journey Each facility and payer will often have a case manager involved and accountable

Follow up physician services Continuum of Care Home Health DME Transportation Out patient services Follow up physician services

In Patient Facilities Solutions These services coordinate with the hospital or other referring facility Coordinate admission and work on discharge Assure continuity of care throughout the continuum Knowledgeable with regards to the pre admission process both financially and appropriate care levels