HSC 6636: Acute Care 1 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Topics History Categories of Acute Care Acute Care in Hospitals Hospital Organization Issues and Trends “Over several decades, an increasing proportion of acute care has moved to outpatient settings driven by financial incentives, advances in medical technology, and physician and patient preferences.” Text (p. 192)

HSC 6636: Acute Care 2 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida History The history of acute care includes themes we have seen before 1800s and before saw acute care primarily home- centered –Family care ‒ Non physician practitioners –Physicians ‒ Little role for hospitals

HSC 6636: Acute Care 3 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida History (cont.) Early 1900s saw increased roles for hospitals –Improved hygiene, asepsis, and anesthesia and improving equipment Improved hospital outcomes Shifted demand for hospital services (displacing some home care) Displaced long term care provided in hospitals –Solo practitioner physician—hospital relationship takes shape

HSC 6636: Acute Care 4 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida History WW II Era and Beyond –Increased effectiveness, availability, and demand for acute care services, including hospitalization Antibiotics Health insurance Hospital subsidies Medicare/Medicaid Modern Era –Increased reliance on NP and PA –Wide range of settings for care

HSC 6636: Acute Care 5 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Categories of Acute Care Ambulatory –Outpatient basis w/ no overnight hospital stay –Many settings –Less of a longitudinal relationship between patient and provider

HSC 6636: Acute Care 6 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Categories of Acute Care (cont.) Ambulatory Care (cont.) –Conditions for which ambulatory care has traditionally been provided –Shifting new conditions to ambulatory status New technologies reduce hospitalization Cost containment pushes “elective” hospitalization into ambulatory arena Reducing hospital stays pushes more follow-up care to ambulatory setting Managing chronic conditions reduces demands for hospitalization for acute episodes

HSC 6636: Acute Care 7 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Categories of Acute Care (cont.) Ambulatory Care Statistics –82% of ambulatory visits to physician offices –8% hospital outpatient departments –10% to hospital emergency departments –3.8 visits per person per year –Highest usage from more affluent, white, women Also higher usage of physician offices Less affluent rely on emergency departments

HSC 6636: Acute Care 8 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Categories of Acute Care (cont.) Ambulatory Care Organization –Physician offices account for majority of visits –New delivery methods often hospital sponsored to reduce demands on hospital facilities Walk-in clinics Outpatient clinics Stand-alone surgery centers

HSC 6636: Acute Care 9 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Categories of Acute Care (cont.) Primary Care –Expectation of longer term relationship between provider and patient –“A person seeking medical care directly from various subspecialists as the need may arise, but who has no principal ongoing relationship with any of them, would be using ambulatory care but not primary care.” (p. 197)

HSC 6636: Acute Care 10 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Categories of Acute Care (cont.) Primary Care (cont.) –Taking on increased prominence with rise of MCO –Providers include Physicians Nurse Practitioners * PAs * Nurse-midwives –* Can perform 75-90% of services a physician usually provides –Some specialists may become PCP for appropriate patients

HSC 6636: Acute Care 11 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Categories of Acute Care (cont.) Emergency Care –Multiple roles True emergencies –Recognized medical specialty –Specific equipment and procedures Walk-in for less ill –Uninsured –Uncertain Resource rich primary care environment to assess patients with serious problems

HSC 6636: Acute Care 12 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Categories of Acute Care (cont.) Specialty Care –Care by specialists for acute conditions –Surgical ambulatory care for less debilitating procedures 16.4% of surgery outpatient in % outpatient by 2005 –Imaging services provided through Specialty imaging practices Physician offices

HSC 6636: Acute Care 13 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Acute Care in Hospitals

HSC 6636: Acute Care 14 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Acute Care in Hospitals (cont.) Behind the Numbers –Increasing population Admissions per person holding steady –Aging population –Crowding –Demand for outpatient services

HSC 6636: Acute Care 15 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Acute Care in Hospitals (cont.) Teaching Hospitals –Part of an academic medical school and/or; –Offer residency programs –May have medical school faculty on staff –Disproportionate share of uncompensated care delivery –Mixed benefits to patients Much care delivered by trainees Access to highly qualified faculty

HSC 6636: Acute Care 16 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Acute Care in Hospitals (cont.) Public Hospitals –Supported by government funds (in addition to fees) Direct operation by government Operation by a separate government supervised agency Operated by a not for profit company under contract with a government –Often serve underserved areas

HSC 6636: Acute Care 17 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Acute Care in Hospitals (cont.) Public Hospitals (cont.) –Typically larger when in urban areas –“Safety Net” providers –Only 2% of nation’s hospitals but provide 25% of uncompensated care –Other community roles Public health Outreach and education Disaster planning

HSC 6636: Acute Care 18 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Acute Care in Hospitals (cont.) Rural Hospitals –About 2/5 of hospitals classified as ‘rural’ –Much smaller than urban hospitals –Facing shifting demographics Older and poorer –Difficulty providing expensive technologies Difficulty attracting physicians –Disproportionately hit by Medicare reductions but with some offsets

HSC 6636: Acute Care 19 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Acute Care in Hospitals (cont.) Multihospital/Integrated Healthcare Systems –Half of hospitals part of larger entities Chains or networks Holding companies HMO –Network: Group of providers working together –Multihospital System: Members under the same management umbrella Often an ownership relationship –Alliance: A formal organization to integrate operations of members

HSC 6636: Acute Care 20 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Hospital Organization Hospitals which of a wide range of services to provide –Driven by available practitioners –Needed investment –Demand & competition Physicians control admissions Hospitals provide support services –Labs ‒ Imaging –Pharmacies ‒ Facilities –Nursing ‒ etc.

HSC 6636: Acute Care 21 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Hospital Organization (cont.) Physician Relationships –Previous coverage –Note that physician orders for hospital services are not paid by the physicians Governance structures –Traditional/departmental—dual authority structure –Divisional—more integrated support services –Independent-corporate—Medical stall a separate legal entity –Parallel—Professionals time-share their efforts

HSC 6636: Acute Care 22 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Hospital Organization (cont.) Governance models can vary –Often committees with varying authority –Management staff –Executive committee –Board of directors

HSC 6636: Acute Care 23 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Issues and Trends Team Based Care –Construct a team focused on the patient’s needs –Leverages each member’s expertise –Minimizes distractions away from primary strength –Minimizes on-site time for office-based members Patient-Centered Care –Recognizes need for patient engagement –Incorporate patient preferences –Has lead to reduced aggressive treatments

HSC 6636: Acute Care 24 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Issues and Trends (cont.) Physician Training –New trends recognize pros and cons of managed care trends –Emphasize continuity of care including outside of hospital setting –Reducing residency work requirements Increases demands for physician extenders

HSC 6636: Acute Care 25 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Issues and Trends (cont.) Access to Care –Acute care providers must deal with number of uninsured/underinsured patients –$40.7 billion cost for uncompensated care in 2004 –Increasing complexity of conditions as patients defer care

HSC 6636: Acute Care 26 Dr. Lawrence West, Health Management and Informatics Department, University of Central Florida Issues and Trends (cont.) Costs of Care –Cost containment strategies addressing Reimbursement mechanisms Changes to practice including managed care More aggressive resource management –Shifting more care to ambulatory environment –Addressing administrative complexities –Increasing use of information technologies