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

2. 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

3. 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

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

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

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

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

8. Pharmacy Patient Education Laboratory Chemistry Microbiology Pathology
Morgue
Blood Bank

9. 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.

10. 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.

11. 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

12. 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.

13. 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.

14. 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.

15. 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.

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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.

23. 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.

24. 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

25. 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.

26. 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.

27. 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

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

29. 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