subacute healthcare

Indications

• one or more specific active, complex or unstable medical conditions, or
• administration of technically complex treatment

Advantages

• potential for better clinical outcomes
  • goal-directed care to multiple subacute problems
  • strong emphasis on rehabilitation
  • less iatrogenic problems through greater oversight
  • emphasis on outcomes
• smoother transitions between integrated levels of care
  • care given in most appropriate setting
• cost savings

Notes

general characteristics:

• comprehensive inpatient care after acute medical condition has been stabilized
• care is provided immediately after, or instead of, acute hospitalization
• determined course, known treatment, expected improvement
• goal oriented
• care time is limited; until goals are met or no further progress
• no intensive or invasive diagnostic or treatment procedures
• intensity of care is less than acute hospital, but greater than nursing home
• interdisciplinary team approach
• specially trained staff
• patients, not residents
• frequent visits from medical doctor necessary
• less expensive than hospital or acute rehabilitation setting

Increased utilization of subacute care:

• shorter acute hospital stays, resulting in sicker patients
• growing geriatric population
• growth in managed care & integrated delivery systems
• technology advances makes many treatments available outside acute hospital setting
• Medicare reimbursement (before PPS) attractive if criteria met
• increasing acceptance of alternative healthcare delivery sites

Patient characteristics:

• subacute rehabilitation
  • stroke
  • hip fracture
  • short-term (days-weeks)
• medically complex
  • intravenous antibiotics
  • stage IV pressure ulcer
  • short-term (days-weeks)
• chronic care
  • ventilator patients
  • spinal cord or brain injury
  • AIDS
  • long-term (months-years)

Subacute units/providers:

• hospital-based
• free-standing
• Certified Distinct Part (CDP)/Medicare certified beds
• long-term care hospitals
• joint ventures
• integrated delivery systems

Hospital-based Subacute Units:

• common governing board, administration, oversight committees, credentialing processes & bylaws with the acute hospital
• physically associated with the acute hospital
• patients tend to be more acute
  • more nursing time
  • more MD involvement
  • acute medical condition is often focus of care
• better back-up for high acuity patients
  • long-standing close relationships with MDs
  • more consultant availability
• higher usage of ancillary services
  • shorter turn-around times
  • greater use of supplies
  • more effective inventory control needed
  • better equipment maintenance: in house BioMed depts
• on site MD availability is better:
  • more convenient for most MDs
• higher ratio of RNs to LVNs & CNAs
• share risk management approaches & techniques of an acute hospital
• overhead costs higher than free-standing units
• reimbursement is the same as free-standing units

Free-standing Subacute units:

• liability may be higher than hospital-based units
• risk management approaches often not well developed
• overhead costs less than than hospital-based units; reimbursement is the same
• patient acuity tends to increase if they do a good job

Comparison of subacute vs nursing home patients

• subacute patients generally
  • have shorter stays
  • are younger
  • on more medications
  • more problems amenable to rehabilitation
  • less likely to be cognitively impaired
  • greater acuity
  • use more ancillary services
• reimbursement is higher for subacute patients
• both under OBRA 87 guidelines

Certification:

• JCAHO
• CARF

Subacute healthcare functions

• cancer chemotherapy
• burn management
• pulmonary/ventilator management
• pain management
• AIDS care
• post transplant
• complex wound management
• cardiac rehabilitation
• neurologic/stroke rehabilitation

Key elements:

• high MD involvement
• specialized staffing
• cost accounting
• emphasis on outcomes
• case management
• effective information systems & data management

Admission diagnoses (in decreasing order of frequency)

• hip fracture
• stroke
• IV antibiotics for infection
• acute compression fracture & other fractures
• pressure ulcers & vascular conditions
• cardiopulmonary conditions
• post-operative deconditioning
• cancer

Facility outcome measures:

• patient, family, staff satisfaction
• functional improvement
• rates of expected outcomes
• rates of nosocomial infections
• rates of discharge to home or nursing home
• rates of hospital readmission, ER visits
• average length of stay
• mortality

Outcome determinants:

• primary diagnosis
• age
• acuity
• comorbidity
• treatment
• complications
• outcomes measurement

Role of physician:

• a hybrid of:
  • member of an interdisciplinary team, managing chronic conditions (nursing home)
  • management of acute conditions (hospital)
• proactive in patient's care
• early & frequent assessment is necessary
  • improve patient outcomes
  • reduce ER visits & hospitalizations
  • reduce consultant use & utilization in general
• frequent communication with the unit nurse manager & case manager
• must be able to work effectively with other members of the interdisciplinary team

Nursing:

• different form nursing in long-term care or acute care
• must understand care of chronic conditions, geriatric syndromes, OBRA regulations, & documentation requirements (guidelines & protocols for common conditons is helpful)
• must be familiar with treatment of acute medical conditions
• must have excellent physical assessment skills
• must have rehab nursing skills & know how to motivate patients
• interdisciplinary team leaders must have leadership & communication skills

Goals:

• treat patient at the lowest acuity level
  • move patients out of higher acuity level quickly when stable
• treat change of condition quickly
  • treatment delays may have poor outcome(s)
• focus on outcomes & appropriateness
  • do what is medically necessary
  • that which doesn't improve outcome(s) needs justification

Additional terms

• 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