subacute healthcare

Indications: 1) one or more specific active, complex or unstable medical conditions, or 2) administration of technically complex treatment Advantages: 1) potential for better clinical outcomes a) goal-directed care to multiple subacute problems b) strong emphasis on rehabilitation c) less iatrogenic problems through greater oversight d) emphasis on outcomes 2) smoother transitions between integrated levels of care -> care given in most appropriate setting 3) cost savings Notes: general characteristics: 1) comprehensive inpatient care after acute medical condition has been stabilized 2) care is provided immediately after, or instead of, acute hospitalization 3) determined course, known treatment, expected improvement 4) goal oriented 5) care time is limited; until goals are met or no further progress 6) no intensive or invasive diagnostic or treatment procedures 7) intensity of care is less than acute hospital, but greater than nursing home 8) interdisciplinary team approach 9) specially trained staff 10) patients, not residents 11) frequent visits from medical doctor necessary 12) less expensive than hospital or acute rehabilitation setting Increased utilization of subacute care: 1) shorter acute hospital stays, resulting in sicker patients 2) growing geriatric population 3) growth in managed care & integrated delivery systems 4) technology advances makes many treatments available outside acute hospital setting 5) Medicare reimbursement (before PPS) attractive if criteria met 6) increasing acceptance of alternative healthcare delivery sites Patient characteristics: 1) subacute rehabilitation a) stroke b) hip fracture c) short-term (days-weeks) 2) medically complex a) intravenous antibiotics b) stage IV pressure ulcer c) short-term (days-weeks) 3) chronic care a) ventilator patients b) spinal cord or brain injury c) AIDS d) long-term (months-years) Subacute units/providers: 1) hospital-based 2) free-standing 3) Certified Distinct Part (CDP)/Medicare certified beds 4) long-term care hospitals 5) joint ventures 6) integrated delivery systems Hospital-based Subacute Units: 1) common governing board, administration, oversight committees, credentialing processes & bylaws with the acute hospital 2) physically associated with the acute hospital 3) patients tend to be more acute a) more nursing time b) more MD involvement c) acute medical condition is often focus of care 4) better back-up for high acuity patients a) long-standing close relationships with MDs b) more consultant availability 5) higher usage of ancillary services a) shorter turn-around times b) greater use of supplies c) more effective inventory control needed d) better equipment maintenance: in house BioMed depts 6) on site MD availability is better: -> more convenient for most MDs 7) higher ratio of RNs to LVNs & CNAs 8) share risk management approaches & techniques of an acute hospital 9) overhead costs higher than free-standing units 10) reimbursement is the same as free-standing units Free-standing Subacute units: 1) liability may be higher than hospital-based units 2) risk management approaches often not well developed 3) overhead costs less than than hospital-based units; reimbursement is the same 4) patient acuity tends to increase if they do a good job Comparison of subacute vs nursing home patients 1) subacute patients generally a) have shorter stays b) are younger c) on more medications d) more problems amenable to rehabilitation e) less likely to be cognitively impaired f) greater acuity g) use more ancillary services 2) reimbursement is higher for subacute patients 3) both under OBRA 87 guidelines Certification: 1) JCAHO 2) CARF Subacute healthcare functions 1) cancer chemotherapy 2) burn management 3) pulmonary/ventilator management 4) pain management 5) AIDS care 6) post transplant 7) complex wound management 8) cardiac rehabilitation 9) neurologic/stroke rehabilitation Key elements: 1) high MD involvement 2) specialized staffing 3) cost accounting 4) emphasis on outcomes 5) case management 6) effective information systems & data management Admission diagnoses (in decreasing order of frequency) 1) hip fracture 2) stroke 3) IV antibiotics for infection 4) acute compression fracture & other fractures 5) pressure ulcers & vascular conditions 6) cardiopulmonary conditions 7) post-operative deconditioning 8) cancer Facility outcome measures: 1) patient, family, staff satisfaction 2) functional improvement 3) rates of expected outcomes 4) rates of nosocomial infections 5) rates of discharge to home or nursing home 6) rates of hospital readmission, ER visits 7) average length of stay 8) mortality Outcome determinants: 1) primary diagnosis 2) age 3) acuity 4) comorbidity 5) treatment 6) complications 7) outcomes measurement Role of physician: 1) a hybrid of: a) member of an interdisciplinary team, managing chronic conditions (nursing home) b) management of acute conditions (hospital) 2) proactive in patient's care 3) early & frequent assessment is necessary a) improve patient outcomes b) reduce ER visits & hospitalizations c) reduce consultant use & utilization in general 4) frequent communication with the unit nurse manager & case manager 5) must be able to work effectively with other members of the interdisciplinary team Nursing: 1) different form nursing in long-term care or acute care 2) must understand care of chronic conditions, geriatric syndromes, OBRA regulations, & documentation requirements (guidelines & protocols for common conditons is helpful) 3) must be familiar with treatment of acute medical conditions 4) must have excellent physical assessment skills 5) must have rehab nursing skills & know how to motivate patients 6) interdisciplinary team leaders must have leadership & communication skills Goals: 1) treat patient at the lowest acuity level -> move patients out of higher acuity level quickly when stable 2) treat change of condition quickly -> treatment delays may have poor outcome(s) 3) focus on outcomes & appropriateness a) do what is medically necessary b) that which doesn't improve outcome(s) needs justification

Related

case management; chronic care management Commission on Accreditation of Rehabilitation Facilities (CARF) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Medicare & subacute healthcare prospective payment system (PPS) rehabilitation

References

Smith, R. Jewish Home for the Aging, Reseda CA, 2001