Writing: Care and case management

Assignment Content

Question:

In at least 300 words, explain the differences between care and case management. Do you think one is more important than the other? Share your thoughts.

Be sure to include your APA citations/references.

Chapter 5: This week reading material

Course Materials (Available in the Content area of the course): Pratt. J. Long-Term Care- Managing Across the Continuum. 4th edition. Jones and Bartlett ISBN: 978-1-284-05459-0. 

CHAPTER 5

Subacute and Postacute Care

Learning Objectives

After completing this chapter, readers will be able to:

1.   Define and describe subacute and postacute care for the purpose of clarifying these confusing terms.

2.   Identify where

subacute care

fits in the continuum of care, the services it offers, and the consumers who use it.

3.   Identify sources of financing for subacute care.

4.   Identify and describe regulations affecting subacute care.

5.   Identify and discuss ethical issues affecting subacute care.

6.   Identify trends affecting subacute care for the near future, and describe the impact of those trends.

■ Introduction

This chapter describes subacute (and postacute) care—an often-misunderstood segment of the continuum of care—discussing its development, reasons for that development, and where it currently fits in the continuum, as well as the nature of the consumers who use subacute care and what they seek from it. It is misunderstood because it contains several elements that frequently overlap and are referenced by different names. The terms subacute care and postacute care cover some, but not all, of the same services. In fact, discussing both subacute care and postacute care in the same chapter could be called arbitrary. However, we do so in an attempt to bring some clarity to the issue.

We discuss postacute care primarily in the context of explaining the terminology. The chapter explores issues related to financing, staffing, and regulation as they impact subacute care, and it identifies several trends promising such impact in the future.

■ What Is Postacute Care?

Postacute care (PAC)

is designed to improve the transition from hospital to the community. Post-acute care includes the recuperation, rehabilitation, and nursing services following a hospitalization that are provided in

skilled nursing facilities (SNFs)

, inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs), and by home health agencies (HHAs) and outpatient rehabilitation providers. (Dummit, 2011, p. 3)

■ What Is Subacute Care?

While we get to a more detailed definition of subacute care later, for now let us use a simple, straightforward definition. It is “a level of care needed by a patient who does not require hospital acute care, but who requires more intensive skilled nursing care than is provided to the majority of patients in a skilled nursing facility” (CA Subacute Care Unit, 2012). One author suggests we think of subacute care as:

a passageway through which increasing numbers of patients travel. What happens during that experience can range from a set of basic rehabilitation services to a much richer array of therapy, teaching, and medical progress. Medical, and often psychosocial, complexity characterizes subacute care. (Buxbaum, 2009)

■ What Is the Difference Between Postacute Care and Subacute Care?

Both subacute and postacute care are substitutes for acute care, resulting in less cost to the system and to third-party payers and in more convenience for the patient. However, there are differences as shown by the following:

Subacute Care	Postacute Care
May be either after or in place of acute care	Happens after acute care
Provides inpatient services	Provides outpatient services
Provides medical and nursing care	Provides nursing and/or nonmedical care

Postacute care may even be provided following subacute care as an outpatient follow-up to inpatient subacute care.

■ Postacute Care

We begin this discussion with a look at who provides postacute care. Postacute care may be provided in or by several different types of providers, including the following:

•   Inpatient rehabilitation hospitals and units

•   LTCHs

•   Skilled nursing facilities

•   Home health agencies (CMS, 2012)

Each of the multiple PAC settings specializes in certain types of care and therapies, allowing patients to receive a diverse array of services ranging from intensive medical, rehabilitation, and respiratory care to in-home follow-up, such as changing dressings or administering medication. Patients receive a unique set of services in each PAC setting, though some services may be available in more than one setting. Selecting the most appropriate setting for a given patient may involve multiple factors. Some patients may benefit from care at multiple PAC settings during a single episode of illness (AHA, 2010). Because both skilled nursing facilities and home health agencies are discussed in detail elsewhere, we discuss them here only as they relate to the others in postacute care or subacute care. Let us examine the other two categories (inpatient rehabilitation facilities and long-term care hospitals) here. It is also worth noting that postacute care may also be provided in outpatient settings and adult day care. However, these services are not covered by

Medicare

and are not significant in terms of the number of patients utilizing them as postacute care.

Inpatient Rehabilitation Facilities

In a broad sense, rehabilitation services are measures taken to promote optimum attainable levels of physical, cognitive, emotional, psychological, social, and economic usefulness and thereafter to maintain the individual at the maximal functional level. The term is used to denote services “provided in inpatient and outpatient settings, ranging from comprehensive, coordinated, medically based programs in specialized hospital settings to therapies offered in units of hospitals, nursing facilities, or ambulatory centers” (AHA, 2013). Subacute rehabilitation care provides continuity of care for patients who no longer require hospitalization but still need skilled medical care in a rehabilitation facility. Subacute rehabilitation is recommended when a patient is not functionally able to return home. Instead, during recuperation, patients receive rehabilitation in a skilled nursing facility. Medicare requires that skilled nursing facilities provide an intensive rehabilitation program, and patients who are admitted must be able to tolerate 3 hours of intense rehabilitation services per day. For classification as an IRF, a percentage of the IRF’s total patient population during the IRF’s cost reporting period must match 1 or more of 13 specific medical conditions (CMS, 2012).

In 2001, the Centers for Medicare & Medicaid Services (CMS) published a prospective payment system (PPS) for Medicare IRFs as required by the Balanced Budget Act of 1997. The payment system, which became effective January 1, 2002, significantly changed how inpatient medical rehabilitation hospitals and units are paid under Medicare.

The number of inpatient rehabilitation facilities declined slightly in 2009 after remaining stable for several years before that (MedPac, 2013).

Long-Term Care Hospitals

LTCHs “typically provide extended medical and rehabilitative care for patients who are clinically complex and may suffer from multiple acute or chronic conditions. Services may include comprehensive rehabilitation, respiratory therapy, cancer treatment, head trauma treatment, and pain management” (CMS, 2012, p. 7).

LTCHs are certified as hospitals, meeting the same minimum staffing requirements, range of services, and life-safety standards. In addition, LTCHs are required to have an average Medicare length of stay of more than 25 days, which is intended to ensure that their patients are medically complex. LTCHs that are located within an acute care hospital—the fastest growing segment of these providers—are subject to additional requirements that limit the share of their patients admitted from the host hospital. The number of LTCHs rose from 278 in 2001 to 432 in 2009. In spite of a moratorium on new LTCHs beginning in October 2007, the number of these facilities continued to grow through 2010, then remained constant from 2011 to 2012 (MedPac, 2013). In some areas of the country where they are not available, acute care hospitals and SNFs substitute (Dummit, 2011). IRFs are either freestanding facilities, sometimes called rehabilitation hospitals, or rehabilitation units located within acute care hospitals (Singh, 2010).

While Medicare covers LTCHs, there has been concern that they are not an efficient use of resources. Although each of the other types of postacute care (IRFs, skilled nursing facilities, and home health) has standardized data collection and systems, no assessment instrument is mandated for LTCHs (CMS, 2012).

Use of Postacute Care

About one-third of hospital patients go on to use postacute care. The most common, single, postacute care destination for beneficiaries discharged from acute inpatient care hospitals is a skilled nursing facility. Although some episodes involve multiple settings, they generally include only one postacute setting (MedPac, 2013).

Medicare Conditions of Participation

Postacute providers must also meet different conditions of participation. For example, physicians must be integrally involved in care provided in rehabilitation facilities and long-term care hospitals, but are required to visit an SNF patient only once every 30 days for the first 90 days and every 60 days thereafter. Requirements for physician involvement in home health care are even less stringent.

Rehabilitation facilities are required to have 75% of their admissions in 1 of 10 specific diagnoses related to conditions requiring rehabilitation services. LTCHs’ only condition of participation in addition to those required of all hospitals is to have an average Medicare length of stay greater than 25 days (MedPac, 2013).

As one can see, Medicare is a major factor influencing postacute care services due to its reimbursement of those services and the rules that go with that reimbursement. Postacute care currently makes up about 11% of Medicare’s total spending (MedPac, 2013). The CMS has been concerned that the system for reimbursing and monitoring postacute care is poorly defined and contains some inconsistencies, and it has implemented a postacute care reform plan. That plan calls for a demonstration project to assess the system and develop reforms (MedPac, 2013).

Bundled Payments

Like other Medicare-certified providers, postacute care providers will be impacted by the CMS’s Bundled Payments for Care Improvement initiative. Under the Bundled Payments initiative, organizations known as accountable care organizations will enter into payment arrangements that include financial and performance accountability for episodes of care. The hospital-based accountable care organizations will receive the Medicare payments for all other services and will contract with long-term care providers for postacute care. Medicare will pay the accountable care organizations for covered services delivered during an episode of care that is initiated with a hospitalization and continues for 30 days after discharge (Dummit, 2011). The accountable care organizations will then pay the contracted providers and will be held accountable by the CMS for the quality outcomes associated with this postacute care.

Readmissions

The Affordable Care Act of 2010 reduces payments to hospitals for greater-than-expected readmissions, decreasing payments for all Medicare discharges in the prior year. Acute care hospitals and PAC providers will work to reduce rehospitalizations (AHA, 2010).

■ Subacute Care

Having hopefully clarified the terms subacute care and postacute care, we focus the remainder of this chapter on subacute care, referencing postacute care as needed.

How Did Subacute Care Come to Be?

Subacute care

is probably one of the newest entries into the continuum of care. (Probably is used here because of the rapidity with which new types of care and mutations of established types of care are emerging.) It is also one of the fastest growing segments of the healthcare delivery system. Over the past several decades, it has grown and developed, slowly at first, then more rapidly. It has also become somewhat better defined. At first, it was best defined by what it was not. It was not really acute care, nor was it long-term care. It was pretty much anything that fell in between the two. As the healthcare field reacted to the forces at work on it during the 1980s and 1990s (forces such as pressures to be cost effective, increased demand for consumer choice, and competition between providers), subacute care found its niche. It became a defined service instead of a somewhat nebulous gap filler.

Defining Subacute Care

Subacute care

includes post-acute services for people who require convalescence from acute illnesses or surgical episodes. These patients may be recovering but are still subject to complications while in recovery. They require more nursing intervention than what is typically included in skilled nursing care. (Singh, 2010, p. 15)

It is a level of care needed by a patient who does not require hospital acute care but who requires more intensive skilled nursing care than is provided to the majority of patients in a skilled nursing facility. Subacute patients are medically fragile and require special services, such as inhalation therapy, tracheotomy care, intravenous tube feeding, and complex wound management care. Pediatric subacute care is a level of care needed by a person less than 21 years of age. These patients generally use medical technology to compensate for the loss of a vital bodily function (CA Subacute Care Unit, 2012).

Philosophy of Care

Subacute care is specific care rendered for very specific reasons. Conditions that may be appropriate for inpatient subacute care include but are not limited to:

•   Cardiac recovery

•   Oncology recovery—receiving chemotherapy and radiation

•   Pulmonary conditions

•   Orthopedic rehabilitation

•   Neurological disorders/cerebrovascular accident

•   Complex wound management

•   Intravenous therapy (Anthem, 2013)

Initially, subacute care was seen as a form of postacute care, or treatment rendered immediately after acute hospitalization. Over time, it also began to be used in place of acute hospitalization, both as a cost-saving measure and in the interests of providing treatment in the least restrictive location and manner.

It is generally thought of as a transitional phase of care, moving the patient to home or to a long-term care facility in a short time. However, there are other variations. There seem to be four generally agreed-upon categories of subacute care, best defined by Kathleen Griffin in her Handbook of Subacute Care, which has become the authority on the subject (Griffin, 1995). The first category she identifies is

transitional subacute care

, which is usually quite short term, serving as a means of transitioning from highly intensive hospital units while maintaining the availability of acute care if needed. As such, transitional units are usually located at or near hospitals and operated by those hospitals.

A second type of subacute care is referred to as

general subacute care

. Lengths of stay are somewhat longer for those receiving general subacute care than those in transitional units. Patients needing ongoing therapy or monitoring fall into this group. General subacute care units are apt to be owned and operated by either hospitals or nursing facilities (Griffin, 1995).

The third category is

chronic subacute care

. These units care for patients with serious chronic conditions requiring services such as ventilator or intravenous therapy. Their average stay is longer than the transitional or general subacute care units, but most patients stay only about 60 to 90 days before they are transferred to a lower level of care or before they die (Griffin, 1995).

The last category described by Griffin is

long-term transitional subacute care

. It is usually hospital-based care for patients with more complex medical problems who need more intensive (but still not acute) care over a longer time before transitioning to home or another level of care (Griffin, 1995).

Thus, subacute care, as a portion of the continuum, is best defined in terms of the type, amount, and duration of care given. There is emphasis on staff with skills in assessment of patients’ conditions and the ability to adjust treatment plans as needed. They must also be skillful at managing specific conditions such as strokes or post–cardiac surgery and in performing specific procedures such as ventilator therapy or pain management. Although Griffin’s book is 2 decades old, these categories and definitions are still valid and one of the best ways to differentiate the various forms of subacute care.

Ownership of Subacute Care Units

As noted earlier, subacute care is identified by the services offered, not necessarily by who the providers are. Often, subacute care is provided by existing hospitals or freestanding nursing facilities. Increasingly, both groups are becoming part of integrated healthcare networks. Subacute care units, when affiliated with hospitals or nursing facilities, are usually classified as SNFs by Medicare for reasons of reimbursement and are often the result of reclassifying beds in a designated unit.

Freestanding SNFs are the most prevalent form of subacute care, followed by hospital-based units. The hospital-based units generally function as swing-bed units, allowing the patient to change classification without actually moving.

An important trend in ownership of subacute care units, a trend supported by all available studies, is the large proportion owned and operated by chains, either regional or national. They have the financial resources and staff expertise to develop and operate such services where many independent owners do not.

Services Provided

Services provided in subacute care units vary depending on the nature of the population served, but might include the following:

•   Rehabilitation

•   Physical and occupational therapy

•   Respiratory therapy

•   Cardiac rehabilitation

•   Speech therapy

•   Postsurgical care

•   Chemotherapy

•   Total parenteral nutrition

•   Dialysis

•   Pain management

•   Complex medical care

•   Wound management

•   Ventilation care

•   Other specialty care

Planning how care will be delivered to consumers is important in all forms of health care, but the terms 

care planning

 and 

case management

 have taken on more importance in subacute care than in some of those others, largely due to the influence of reimbursement sources. Care planning is discussed next; case management will be discussed later in this chapter.

Care Planning

A key to successfully providing subacute care is good care planning. It involves assessing each individual patient’s needs, developing a care plan to meet those needs, and constantly reviewing the care plan and adjusting it as needed. If not done carefully, by qualified staff, care planning may produce negative results, including longer-than-necessary lengths of stay or inadequate treatment. The former results in excessive costs to the organization. The latter leads to dissatisfied patients, which, in turn, may lead to dissatisfied reimbursement organizations.

The care plan begins with a detailed assessment of each patient. Members of the

interdisciplinary team

must have assessment skills in addition to knowing how to provide specific treatments. The entire team is involved in the assessment process, and each member has something specific to offer. It is their collective evaluation that results in a good care plan. Together, they develop care goals for the patient—goals that might focus on returning the patient to home, improving or maintaining the level of functional independence, stabilizing a medical condition, or any of a variety of similar end results. Those goals must be accurately defined and clearly understood by all involved, including the patient.

There must be clearly established admission criteria to determine the parameters within which the team may work. Those criteria should be explicit and include definitions of the types of patients and patient conditions for which the facility is qualified to care.

Care planning by the interdisciplinary team is not a one-time occurrence. It goes on throughout the course of treatment. It is generally recognized that the team will hold care-planning conferences to review the plan and the patient’s progress at least weekly, more often if the patient’s medical or functional status changes. It must be a dynamic process, capable of quickly identifying and assessing changes and responding to them in a timely and appropriate manner, which requires that the team members be skilled in assessment techniques.

These interdisciplinary team meetings should include all who are involved in the patient’s care, as well as the patient, family members, and other caregivers. It is an information-sharing session as well as an opportunity to evaluate progress against the original care plan.

The care plan, including the assessment on which it is based and the periodic evaluation and adjustments of that plan, does not represent the end of the process by a long shot. To be successful, subacute care must include an outcomes-based measure of how well the program met its goals. There must be a process for determining the effectiveness of the treatment plan. That effectiveness is measured by changes in the patient’s medical or functional status from the beginning of the program to the end. It also includes periodic measurement against predetermined benchmarks during the treatment process.

Measuring Quality of Care

There are numerous excellent tools available for measuring outcomes-based effectiveness. For example the

CARF International

(formerly the Commission on Accreditation of Rehabilitation Facilities) program evaluation system contains excellent processes for measuring functional outcomes. Providers have also dealt with a couple of other programs: quality assurance and continuous program improvement—also known as program improvement—that have been replaced by quality assurance and performance improvement (

QAPI

).

QAPI

QAPI is the merger of two complementary approaches to quality: quality assurance and performance improvement. Both involve seeking and using information, but they differ in key ways:

•   Quality assurance is a reactive, retrospective process of meeting regulatory quality standards.

•   QAPI is a proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems.

QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. According to the CMS, the activities of QAPI “involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions” (CMS, 2013).

Whatever process, or combination of processes, a subacute care program chooses to utilize, there must be a method of measuring what the program accomplished on behalf of its patients. Patients will seek that information, as will agencies providing reimbursement, and any licensing or accreditation organizations involved. Even if they did not, the provider needs to know how well it is performing. Anecdotal evidence of patient satisfaction is valuable but should be supported by some type of tangible, quantifiable confirmation that the program is producing the results it expects and promises.

Outcomes measurement should not stop at discharge. Most subacute care services are aimed at producing results that will improve the patient’s medical or functional status. If effective, those results will last, at least for a reasonable period. Yet, the very nature of the conditions being treated causes those results to diminish over time. An effective outcomes measurement program will extend beyond discharge far enough to document how well the treatment results lasted, usually at least 90 days. It provides the program with information about how well the patient was prepared for discharge, indicating the efficacy of follow-up arrangements and the preparation of the patient to continue treatments or to maintain the functional or medical status achieved while receiving subacute care.

Both quality and cost outcomes should be measured. It is obviously important that the quality and efficacy of care be proven. However, payment sources, particularly

managed care organizations (MCOs)

, expect subacute care providers to document their efficiency as well.

Postdischarge measurement also provides a mechanism for detecting problems with the discharge planning process and sometimes with the plans themselves. It identifies potential slippage in the patient’s status, indicating the need for further, more intense intervention. As such, it is an integral part of the entire treatment process. Just as there must be clear criteria for admission to the subacute care organization, so must there be criteria for discharge. The unit must have transfer agreements with appropriate facilities so that the care-planning team is able to discharge appropriately and in a timely fashion, without unnecessary delays or gaps in coverage.

Case Management

There is another element in managing the process of providing subacute care. It is case management, not to be confused with

care management

. While care management is concerned with the type and quality of care received, case management’s primary goal is the cost-effectiveness of the care given.

The actual process of case management parallels the care-planning process, with many similarities. In fact, the

case manager

is an integral part of the interdisciplinary team and is involved each step of the way. The difference is that the case manager’s focus is more on the degree of efficiency with which care is given. He or she manages the utilization of resources expended in providing care.

Case managers are often employed by payers, particularly MCOs, to protect their interests. Those external case managers often have powers to approve or disapprove treatment, including specific procedures. They seek to control high-cost procedures, limiting or eliminating expenses deemed unnecessary.

There may not always be an external case manager in subacute care, depending on the payer, but there will usually be an internal case manager employed by the unit. That person’s job involves both patient outcomes and cost. The internal case manager is more closely involved with the patient care team than the external case manager is likely to be. In fact, one major role of the unit’s case manager is to act as a liaison with the case manager employed by the payer and to negotiate with the payer’s representative to secure authorization and payment for needed supplies, equipment, and procedures. He or she also functions as a liaison with other entities, including the clinical team, the patient, and the patient’s family. Lastly, do not get the impression that the subacute care organization’s case manager is only concerned with minimizing costs. That person is also the patient’s advocate. A clinical background is very useful.

The role requires a combination of coordination, monitoring, and control. The internal case manager must be knowledgeable of the rules governing payment for services and must keep up with any changes in eligibility or coverage provisions that would affect reimbursement to the provider.

The use of case managers by the providers and payers has become standard practice in subacute care and some other types of health care. It is based on a sound philosophy of managing the process of providing care to ensure that it is efficient, cost effective, and not unnecessarily expensive. However, it raises certain questions and has led to some disagreement and controversy, particularly among healthcare policy makers. The case manager functions as a

gatekeeper

—the person who controls access to care. Who should be the gatekeeper? Can anyone objectively serve the three principal participants (the patient, the provider, and the payer)? When the gatekeeper works for the provider, the payer worries that unneeded services will be provided to generate revenue. At the same time, the patient worries that the provider will skimp on services to save expenses. If the payer employs the gatekeeper, the provider and patient both worry that cost will take precedence over quality or even over required care. Lastly, if the patient or a surrogate (an ombudsman, legal representative, or other advocate) serves as gatekeeper, the provider and payers fear excessive use of services at their expense.

Who should be the gatekeeper? There is no easy answer. Perhaps the most effective, but certainly not the neatest or most efficient, solution lies in having three gatekeepers who each represent one of the parties. Through a system of checks and counterchecks, they keep each other in balance. The one who is most likely to be at a disadvantage is the patient, who has to rely to some degree on the good faith and honorable intentions of the others to act in his or her best interests. It is an interesting dilemma and one for which subacute care may be leading the way toward a system that comes closest to a solution. The relative newness of subacute care leaves more room for experimentation and innovation than some of the more traditional segments of health care. The major role played by MCOs in subacute care, when compared with nursing facilities, home care, and other forms of long-term care, is also increasing the popularity of case management. It is a concept that is here to stay, although its shape may change many times over the next few years.

Consumers Served

Subacute care serves a variety of types of patients, but it tends to treat more of some types than others. They are patients needing a high level of skilled care, generally with a defined treatment plan and timetable for discharge or transfer to another type of care. They need rehabilitation, monitoring, or other specialized treatment. People of all ages require and receive subacute care, but as with most long-term care, the majority are elderly.

■ Market Forces Affecting Subacute Care

Subacute care has grown in response to several factors in the healthcare environment.

Cost-Saving Efforts

The primary force has been financial. With the replacement of the historical, retrospective, cost-based method of reimbursing hospitals by a PPS, hospitals came under considerable pressure to keep lengths of stay in acute care as short as possible. At the heart of PPS was a system of

diagnosis-related groups

. Under the system of diagnosis-related groups, hospitals were being reimbursed for the episode of illness, not by the day. They sought ways to discharge patients earlier or to find less expensive settings for them. This set up a general movement within the healthcare system of patients to a lower level of care intensity. It, in turn, raised the acuity level of patients/residents at each level. Subacute patients did not need the high-end acute services offered by hospitals but needed more than traditional nursing facilities were equipped to provide.

Providers and reimbursement agencies alike quickly realized that a care/payment category in the middle made sense. Reimbursers—primarily Medicare—were able to pay a lower rate for subacute services than they would for acute care. Hospitals received a rate lower than their acute rate but more than a nursing care rate.

Diagnosis-related groups created another market force that also led to creation of more subacute care units. Hospitals found themselves, many for the first time, with low occupancy rates and entire units of empty beds. Creation of a new, in-between, level of care enabled them to fill some of those beds. It also allowed them to legitimately keep patients longer. By converting acute patient units to subacute care, they were able to make more efficient and effective use of their expensive buildings, equipment, and staff. The bundled payments program of the Affordable Care Act places more emphasis on coordination of effort between acute and subacute providers in reducing costs.

Managed Care

The most important market force driving the growth of subacute care, however, has been the emergence and rapid expansion of managed care. MCOs have found subacute care to be an excellent resource for them in their quest to find lower cost alternatives to acute hospitals.

Nursing

care facilities have also found reasons to enter the subacute care arena, including making themselves attractive to MCOs. Their administrators are faced with both an opportunity and a challenge to meet higher demands for managed care (Singh, 2010).

Medicare and MCOs were not the only reimbursers seeking ways to reduce their costs. Others, such as private insurance companies, spurred on by their corporate customers, were also reacting to major increases in the cost of providing and insuring health care. They sought mechanisms for controlling those costs, including mandatory second opinions and preadmission authorization. Subacute care gave them an opportunity to cover needed care for their policyholders at a lower cost.

Many nursing facilities also foresaw the competition coming from hospitals and decided to get into subacute care as a means of expanding, or at least maintaining, their market share. Others were not as proactive, but many of them have come to realize that subacute care is an area that they can share with hospitals or be left out.

Choice

Another, nonfinancial force affecting the growth of subacute care was the rising demand by healthcare consumers for more choice in their care. They made it very clear that they want as much care as is necessary but do not want to be in what they see as more restrictive acute hospitals if it is not needed. Again, subacute care units provide them with a middle-ground alternative.

■ Regulations

Subacute care was created in part because of regulations (primarily those associated with the prospective payment system); thus, has it been further shaped and defined by regulations. Subacute care is similar to other parts of the continuum of care in that it is governed by a plethora of regulations. It is, however, somewhat different from the more established entities such as hospitals and nursing facilities because of its relative newness. It is still somewhat immature as a regulated industry segment, but it is rapidly catching up with the other provider groups.

Just as subacute care is neither hospital care nor nursing facility care as such, it has been treated as a kind of hybrid by regulators. Hospital regulations do not fit it well. Although applied to subacute care, they have not adequately met the needs of either providers or regulators in that area. Nor have nursing facility regulations. Those regulations were designed for other types and levels of care, with different patient populations, care goals, and staffing. Healthcare regulations dealing with quality of care, reimbursement, and management of one type of provider cannot readily be applied to another in a one-size-fits-all manner. That is particularly true when there are already several different sets of regulation applying to older types of service providers.

For example, federal law requires that all nursing facility administrators be licensed in their respective states, but there is no such regulation applicable to hospital administrators. If subacute care fits somewhere in between, should their administrators be licensed or not?

There is need for regulations tailored to subacute care. It is an established form of healthcare service. Although newer than most others, it has enough of a track record for regulators to use to create appropriate regulations that protect consumers from poor quality and the government from excessive costs. Current regulations do neither adequately. Yet, because they are being applied, they often serve as obstacles to providers who are trying to further refine this growing field.

Other regulations to which subacute care providers are subject come from several different sources, as do those covering other types of health care. However, the lack of subacute-specific regulations muddies the waters even more.

Medicare certification regulations cover areas such as staffing, length of stay, organizational form, patients’ rights, and required services. Subacute care providers find it difficult to comply with them because there are discrepancies from one type of provider to another in some of those regulations.

Other regulations applying to subacute care are those associated with the Omnibus Budget Reconciliation Act of 1987 (OBRA). Also referred to as the Nursing Home Reform Act, OBRA made major changes in the long-term care industry. Its rules, which are very prescriptive concerning such things as facility design, staffing patterns, care plans, and services provided, are much more rigid than those to which hospitals are accustomed. However, they have been determined to apply to all SNFs certified by Medicare, including hospital-based units. Hospitals have found themselves hard pressed to conform to those more definitive regulations.

Medicaid regulations also affect subacute care providers, although they vary from state to state. There are often crossover regulations affecting both Medicare and Medicaid, particularly in terms of eligibility.

Subacute care providers are also subject to

certificate of need (CON)

regulations where CON laws still are in effect. Certificate of need laws were first passed to control new capital expenditures and services. The purpose of such laws was to limit overall healthcare spending by limiting expansion of services or the building of healthcare facilities. They have been scrapped in many states, but in those states still enforcing CON regulations, subacute care providers must go through a lengthy, and often expensive, review process in order to get approval to create a new subacute care service. Some states have created a virtual moratorium on certain types of new construction. Providers wishing to open a new unit then have to buy a CON approval from another provider, purchase an existing facility’s licensed bed complement, or gain that approval through a joint venture with an organization that has already received such approval. It is not uncommon for potential subacute providers to avoid states with restrictive CON laws still in effect.

While inapplicable, fragmented regulations are the bane of any provider’s existence, and the situation in subacute care is particularly bad, do not think that those providers are not capable of taking advantage of that confusion. They, like providers in any highly regulated industry, know where to find the loopholes and are surprisingly adept at leveraging the system to their advantage, which may lead to some unfortunate gamesmanship between regulators and the regulated, such as the purchase of CONs as just described. Also, some providers have taken advantage of the inability of regulations in those programs to prevent abuses. In response, the CMS—formerly the Health Care Financing Administration—implemented an all-out effort to make changes needed to stop them (Hyatt & Cornish, 1997). It was a laudable effort, but one that might have been avoided, at least in part, if a similar level of effort had been devoted to developing clear, applicable regulations to this new segment of the industry.

Some states have looked at separate regulations for subacute care but have not addressed subacute care directly. This only added to the already high level of uncertainty pervading the field of subacute care. Reform efforts have, however, often resulted in an increase in managed care, including coverage of public constituencies such as Medicaid patients. Those efforts, based in large part on a desire to save money, have indirectly benefited subacute care.

Before leaving this brief look at regulations, it should be noted that subacute care providers are also subject to other types of regulations just as are other healthcare providers and, in most cases, other industries. They are subject to regulations affecting employment and treatment of their staff that come from sources such as the Occupational Safety and Health Administration, the Wage and Hour Division of the U.S. Department of Labor, the Equal Employment Opportunity Commission, worker’s compensation acts, the Americans With Disabilities Act, the Fair Labor Standards Act, the Family Medical Leave Act, and others.

They must also comply with regulations affecting building construction/safety such as the Life Safety Code and local building codes. The Occupational Safety and Health Administration and Americans With Disabilities Act also contain regulations concerning building construction and safety.

■ Accreditation

Voluntary accreditation and certification is much further ahead than regulation in attempting to ensure quality in subacute care. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) and CARF International both took the early lead in implementing subacute care quality standards.

The Joint Commission, instead of developing an entirely new set of standards for subacute care, took portions of its existing hospital and long-term care standards and adapted them to fit this in-between level of care. Actually, the standards are changed little if at all, but the interpretation of those standards, on which the survey is based, was tailored to reflect differences in staffing, care plans, and physical facility requirements. It has worked surprisingly well, although it is not as refined as subacute-specific standards would probably be.

CARF International took a somewhat different approach. It was, after all, focused on rehabilitation and had considerable experience in accrediting agencies and organizations providing a variety of rehabilitation services, as compared with the Joint Commission’s broader healthcare focus. Thus, CARF International included medical rehabilitation, including subacute care, under the overall umbrella of comprehensive rehabilitation programs. Three subcategories were developed, taking into account the different levels and types of rehabilitation care (acute or subacute), the provider location (hospital-based or freestanding skilled nursing facilities), and patient outcome goals. CARF International standards and survey processes have long been more outcome oriented than those of the Joint Commission, but the latter organization has made significant changes over the past few years to the point where it is also focused on outcomes. It should be noted here that CARF International merged with the Continuing Care Accreditation Commission in 2003, but that did not have any significant impact on subacute care accreditation.

The

National Committee for Quality Assurance (NCQA)

is directed primarily at MCOs. However, as subacute care providers or the parent organizations under which they operate wish to contract with MCOs, they must be aware of the NCQA standards, what they are, what they require, and how best to meet them.

Subacute care provider organizations that are part of MCOs will have to meet these standards. However, they are not alone. Other subacute care providers will also have to adopt strategies designed to comply with NCQA standards if they wish to compete successfully for managed care contracts.

Subacute care providers are seeking voluntary accreditation at a much faster pace than are traditional nursing facilities, perhaps reflecting the influence of hospitals, for whom accreditation is a long-standing norm. Accreditation is also a valuable credential for any organization trying to survive in a competitive marketplace to have. Many subacute care units are accredited by the Joint Commission, another group is accredited by CARF International, and a smaller group by state or other accrediting bodies.

In a business without clear regulations to govern it and document excellence or the lack of it, accreditation becomes an even more useful credential to have.

■ Financing Subacute Care

The problems stemming from attempting to use regulations designed for hospitals and/or nursing facilities with subacute care also affect the financing of those services. Because subacute care reimbursement has been in such a state of change, with new rules and formats occurring regularly and numerous demonstration projects under scrutiny, we do not get into a lot of detail about it in this chapter. If we did so, it would probably be out of date before the reader gets to it. Instead, we present a broad overview—enough to provide a basic understanding of how subacute care is financed.

There is no single payer for subacute services, nor is there any standardized payment mechanism. Medicare and private insurance are the primary source for subacute nursing home care funding. Medicare pays 68% while private insurance and individual self-pay account for 22%, with the remainder coming from other sources such as the patient or his or her family (ParentGiving, 2013).

Medicare

Just as Medicare had moved from a retrospective, cost-based payment system to a PPS for acute care hospitals some years earlier, subacute care made a similar move as the result of the Balanced Budget Act of 1997. Under the PPS, providers receive payment based on preestablished rates for specific services instead of receiving direct reimbursement for their costs.

Managed Care

One trend that does seem to be holding true is the increased influence of managed care in financing of subacute care. Recent information suggests that the managed care portion of subacute care is growing very rapidly. Not only are private MCOs growing, both in number and in size, but government programs are also moving in that direction. A majority of states have been experimenting with managed care for Medicaid patients as a cost-cutting measure. Several of the federal initiatives that have been proposed would also encourage managed care for both Medicare and Medicaid.

■ Staffing and Human Resource Issues

Like most other aspects of subacute care, staffing requirements fall somewhere between acute care staffing and nursing facility staffing. There are some basic elements, however, that must be included. Subacute care requires the coordinated services of an interdisciplinary team including physicians, nurses, and other relevant professional disciplines sufficiently trained and knowledgeable to assess and manage these specific conditions and perform the necessary procedures (Anthem, 2013).

An Interdisciplinary Team

First, the subacute care provider must adopt a philosophy of care based on an interdisciplinary team. There must also be an organizational structure that recognizes that approach and supports the philosophy, which is not enough in itself. The actual makeup of the team will vary somewhat but would include a program administrator, a medical director, case managers, and any or all of the following clinical disciplines: other physicians, nursing, social services, psychology, physical therapy, occupational therapy, speech-language pathology, respiratory therapy, recreation therapy, and dietary.

Program Administrator

There must be someone in charge administratively. That person might be called program manager, program director, administrator, or some variation of those titles. What is more important than the title is the clear responsibility and authority the person has for operation of the subacute care unit or facility. The program administrator, as we shall call the position for sake of simplicity, may have a related clinical background or may be trained in health care administration. Regardless of background, the person responsible for running the unit or facility must have good management skills.

Physicians

Physician coverage and direction is critical to the success of the subacute care program. There should be a medical director with designated responsibility for clinical oversight of the program, ensuring its integrity. The medical director may have other duties, including direct care of some patients, as long as those duties do not interfere with his or her primary duties. Ideally, the medical director will be trained in care of the types of patients to be treated. A medical rehabilitation unit would do well to appoint a specialist in internal medicine or a geriatrician. If the focus is more on physical rehabilitation, a physiatrist would be preferable; for cardiac rehabilitation, a cardiologist; and so on. That may not be possible. The unit is very unlikely to treat only one type of patient; it may be hard to find a medical director with training appropriate to all of them, and such specialists are not always easy to find.

Gaps in medical specialty coverage can be filled with other physicians with the needed specialty training and experience. They may be hired on a full- or part-time basis, engaged as consultants, or allowed to admit and treat patients as independent contractors. The choice of method or methods for providing medical coverage depends on factors such as size of the program, number and type of services offered, and availability of physicians with the desired specialties.

Physicians need to visit more often than in the traditional nursing facility, although generally not as often as in an acute hospital. The types of services offered and the acuity of the patients dictate the frequency of physician visits.

Nursing

Nursing coverage is also of critical importance. There must be 24-hour coverage by registered nurses. The actual amount of nursing care per patient per day depends on the type of treatment. Patients in transitional medical programs usually require more than some other rehabilitation patients. Some highly specialized subacute care, such as that in pulmonary rehabilitation or neurobehavioral programs, may require considerably more, even approaching acute staffing levels.

Staffing levels are subject to influence by the source of reimbursement. Government agencies such as Medicare and Medicaid have set minimum staffing requirements and maximum reimbursable expense levels, defining a pretty narrow range within which the provider must work. MCOs, with their focus on cost-effectiveness, have their own ideas about staffing. The provider must be aware of these stipulations, preferably before getting involved.

Other Professional Staff

Subacute care requires a mix of professional staff, including therapists, psychologists, social workers, dietitians, and occasionally others. These disciplines, like the physicians, can be obtained through several different methods, including direct hire, consulting, and contracting through an independent company supplying such services. The volume of patient needs for a particular service component may not justify employment of full-time staff in some of these areas—and they may not be available. In such cases, the program may need to contract with an individual professional or with a contract firm. There are many excellent contract providers supplying specialty professionals to hospitals and nursing facilities. However, there may be disadvantages in using outside sources. For example, it is always easier to generate consistency of interest and effort with in-house staff.

Nonlicensed Staff

The subacute unit will also need a committed, well-trained cadre of nonlicensed workers, including nurse assistants and staff in housekeeping, maintenance, the business office, and medical records. They must also be in tune with the overall philosophy of the subacute program if they are to contribute to it.

Recruitment

Recruitment of staff is important to the success of the program. The proper number and mix of staff are needed for efficient operation. Staff also need to have training in the types of services provided. Those services may include some highly specialized treatments, such as dialysis, intravenous therapy, or wound management. There may be current staff with some of these capabilities if the subacute care program is being carved out of an existing facility or organization. If not, or if the subacute program is an entirely new venture, recruitment becomes particularly critical and must be given an appropriate level of attention and support. People with some of these specialized talents are often difficult to find. In fact, proceeding with development of a new program without ascertaining the availability of required staff ahead of time would be foolhardy at the least and could be disastrous at worst.

The degree to which the organization is able to acquire staff who already have education and experience will determine how much additional training is needed. There will always be some level of training necessary to make sure all staff are equally and adequately qualified. It must also be an ongoing process to keep staff sharp and up to date.

■ Legal and Ethical Issues

Subacute care providers entering the field of subacute care face a number of legal issues. Those issues fall into two general categories: (1) meeting licensure and reimbursement regulations and (2) professional liability.

Licensure and reimbursement issues revolve around getting approval to open and operate a subacute care unit and securing reimbursement for the services provided. These areas involving licensure and reimbursement are closely related. Regulations concerning licensure of the unit are, in many ways, the legal foundation on which reimbursement agreements are based. This is particularly true when the reimbursement, or even a portion of it, is derived from public sources, such as Medicare and Medicaid. Organizations seeking to open subacute care units should study these complex issues carefully, with the assistance of well-qualified legal counsel, preferably with experience in subacute care–related legal matters. Operators of nursing care facilities who are thinking of getting into subacute care should look carefully at several professional liability issues that may be new to them, including malpractice, incident reporting mechanisms, claims management, and credentialing of its professional staff.

■ Management of Subacute Care Units

The program administrator, while responsible for administration of the subacute care function, may fit into a variety of places within the overall organization. If the subacute care unit is a freestanding unit, functioning on its own, the administrator probably reports to a governing board. If it is part of a hospital or nursing facility organization, the subacute program administrator probably reports to an administrator at a higher level in the organizational hierarchy. The same holds true in a multiorganizational integrated healthcare network.

It is important that the administrator have access to needed staff and other resources to do the job effectively and successfully. If subacute care is a new venture for the organization, the administrator should be in place at the very beginning. He or she should have responsibility for staffing and recruitment of staff. The administrator (in any organizational setting) should have confidence in his or her staff. The best way to do that is to hire them. If a new facility is being built or if it requires major renovation of an existing space, the administrator should also be directly involved in that phase of development.

On an ongoing basis, the program administrator has overall responsibility for ensuring the quality of care given; for the effectiveness, efficiency, and productivity of staff; and for planning future activities. Those responsibilities, particularly ensuring the quality of care, may be met through the work of others, but the administrator remains accountable for their success. That requires a well-trained, skillful manager.

Management Qualifications

Subacute care administrators need the same skills as administrators of other healthcare organizations. Administrators of nursing facilities must be licensed by the states, but hospital administrators are not. With subacute care being so new and being delivered in both types of facilities, what assurance is there that the administrators are qualified? The American College of Health Care Administrators developed a program to certify subacute care administrators. That program, with its study materials, provided both training of subacute care administrators and documentation of their skills. It was a voluntary certification, but it was eventually dropped because of lack of interest by the professionals and lack of requirement for it.

Management Challenges and Opportunities

There are many reasons for creating a subacute care unit or facility. It provides an organization with many opportunities for expanded services. It is a means of gaining or protecting a market niche. Even if it only means finding new uses for currently underutilized beds or facilities, subacute care has much to recommend it. However, converting to subacute care also presents some formidable challenges. Let us look briefly at some of them.

Changing the Culture of the Organization

Any time an organization moves from one type of care to another, there are likely to be some changes in its culture. Each organization has its own culture based on a set of principles and/or beliefs that determine acceptable behaviors. Subacute care is just developing its own distinct culture, borrowing from both hospitals and nursing facilities and their established organizational cultures. Yet, either of those entities wishing to move into the subacute care arena must make some fundamental changes as well.

The dichotomy between nursing facilities and hospitals has been described as care versus cure. Acute care hospitals are accustomed to short lengths of stay, intensive medical and nursing care, and high-technology equipment. They, of necessity, place emphasis on curing the patient’s particular malady.

Nursing care facilities, on the other hand, are used to caring for their residents for long periods of time. They focus on the overall person and that person’s quality of life. Even the names given to these consumers of care reflect the differences. When in a hospital, they are called patients. When in a nursing facility, they are seen as residents.

Subacute care is more closely aligned with acute care. It requires relatively high-technology equipment. Services are aimed at treating a medical condition or functional limitation. Lengths of stay are shorter than in nursing facilities but longer than typical hospital lengths of stay. Required staffing patterns are higher than in nursing facilities but lower than in hospitals, both in terms of the staffing mix and the number of hours per day allocated to each patient.

The culture change involved in moving into subacute care is greater for nursing facilities than for hospitals. They must act more like acute care, turning their energies and resources to achieving short-term goals that center on improving a specific condition, instead of focusing on longer term goals related to the resident’s quality of life. They must change their staffing to more closely reflect a medical model of care.

Hospitals moving to subacute care have to change their culture as well. Lengths of stay are longer than those to which they have been accustomed. They must adapt to lower staffing levels. Patients in subacute care expect more amenities related to their personal comfort. They are there longer, are usually not as ill as when in an acute care setting, and expect their living quarters to be more homelike.

These changes in organizational culture are not impossible to achieve. Indeed, many subacute care units have successfully been created out of both hospitals and nursing facilities. The biggest obstacle to doing that is an organization’s inability or unwillingness to recognize that there are differences. It is not enough to simply change the name of a unit, transferring current attitudes and activities, and hoping it will work. Getting all staff, especially highly skilled physicians and nurses, to change their fundamental way of functioning is a challenge for any subacute care administrator.

Balancing Cost and Quality

It is a challenge for any healthcare organization to successfully balance quality of services with cost-effectiveness. Subacute care units are more focused on that than some other healthcare entities. There are several reasons for that, not the least of which is that subacute care came about largely as a means of providing care at a lower cost than in acute hospitals. Had that incentive not been present, it is doubtful that subacute care would have developed as rapidly as it has, if at all.

As was noted earlier, managed care is a major influence on subacute care. MCOs see subacute care as a viable alternative to higher cost treatment in acute care hospitals. As their influence on subacute care providers continues to grow, there is related pressure on those facilities to slash their operating expenses. With that cost-cutting effort comes a responsibility to ensure the continued quality of care. MCOs will not continue to contract with a subacute care provider, no matter how cost effective, if that provider cannot assure a certain level of quality. MCOs have more providers from which to choose; as competition increases in the subacute care industry, so does the need to develop meaningful measurements of facility quality. Achieving success in both cost-effectiveness and quality is not easy and presents an ongoing challenge for subacute care providers.

Coordination and Competition With Other Facilities and Organizations

Subacute care units have experienced, and can expect to continue to experience, a considerable amount of competition as others see the opportunities it presents. At the same time, subacute care units must interact with other organizations if they are to succeed. One of the challenges for any subacute care organization is maintaining a balance between the two forces of competition and cooperation. It must carefully analyze its operating environment, watching for potential collaboration opportunities as well as threats from competitors.

Subacute care is not an organizational entity that can stand on its own well. It must have sources of patients. Few subacute care patients are admitted without some prior admission to an acute hospital or some contact with an MCO and its affiliated hospital or medical staff. To succeed, the unit needs referral agreements with other levels of care. It also needs discharge opportunities for its patients.

Choosing those organizations with whom to associate and those with whom to compete requires a sound analysis and evaluation of the subacute care unit’s own capabilities, its strengths, and its weaknesses, as well as the strengths and weaknesses of potential competitors or collaborators. The subacute care organization may not always have the option of choosing. Those other organizations will be going through the same analysis and evaluation process. The one that does so most effectively will be in the best position to determine its own partnerships.

Subacute care units, even those that are physically freestanding, tend to be affiliated with or owned and operated by hospitals or nursing facilities. Within those parent organizations, there is need to integrate the subacute services with others offered, while maintaining the separateness that is required for reimbursement and accreditation purposes. The physical plant, staffing, administrative oversight, and policies and procedures are all areas that should be addressed if that balance is to be sustained.

Physical Facility Considerations

As we have noted, subacute care units are often carved out of hospitals or nursing facilities. Neither of those facilities is ideal for subacute care, although for hospitals, it primarily means designating a section or a wing of the facility for subacute care. It must be a dedicated unit, either a separate facility, standing on its own, or, if part of a larger facility, physically separated from other patient units.

The unit may already have the necessary technology available. For nursing facilities, the magnitude of change is much greater. They must usually do more and spend more to convert to this different level of care. They should anticipate a significant investment in unit renovation and capital equipment, as well as in upgrading a variety of systems. They will probably have to upgrade the unit, including such improvements as adding piped-in oxygen, electric beds, and other equipment necessary for providing a higher level of care. If rehabilitation services are offered, there will likely be need for additional space for physical and occupational therapies. If the services are primarily medical, other clinical modifications will be needed.

A major change for many nursing facilities entering the subacute care business is the need for a sophisticated information system. Contracting with MCOs, documenting treatments and costs, and maintaining a successful outcomes measurement system require more data-handling capacity than many nursing facilities have traditionally had. NCQA standards require MCOs to practice utilization management. The MCOs, in turn, pass those utilization management requirements on to the providers with whom they contract. Nursing care facilities with strong information systems are more likely to be competitive for MCO contracts.

■ Significant Trends and Their Impact on Subacute Care

Change is a given in any specialty care area as new and relatively undefined as subacute care. Some change comes from trends in overall health care, some from trends more specific to long-term care, and some from trends within subacute care itself. All have the potential for causing significant, and sometimes dramatic, change within the subacute care field. We have discussed some of those trends in our earlier discussions, but let us summarize them briefly.

Managed Care

Clearly, the most important trend affecting subacute care is the increased influence of managed care. It has been a primary factor in the growth of subacute care to date and will continue into the future. Pressures to provide quality care at low cost will not diminish, further fueling the growth of managed care plans. As public entities become more experienced at applying managed care theories and practices to reducing their costs, the demand for niche providers such as subacute care will continue to expand.

That demand will encourage more and more organizations to try their hand in the area of subacute care. Not all will succeed. Some will fail because of poor planning, others because they did not provide adequate resources. A few will fail in spite of good planning and administration, simply because they are outdone by a competitor. Eventually, the field will mature and settle down some, but in the meantime there will be continued turmoil caused by new entries into the field and the resultant casualties.

Changes in Acuity Levels

As managed care and other cost-effectiveness measures continue to seek the least expensive form of care, the acuity level of patients in each type of provider will continue to rise, as it has recently. That trend is supported by consumers’ desires to receive care in the most homelike setting possible. The impact on subacute care will be that patient treatments that, today, are provided in hospitals will be handled in subacute care units. That means that those units will require even more high-technology capabilities. At the other end, nursing facilities will be prepared for more of the treatments that are now commonly performed in subacute care.

Emphasis on Outcomes

Payment sources for subacute care, particularly private MCOs, will continue to emphasize outcomes as a basis for measuring organizational performance. Those outcome measures will contain both quality and cost-effectiveness components and will require that the two be balanced. As Medicare and Medicaid experiment more with managed care, it is likely that they will adopt some of the outcomes measurement systems developed in the private sector. Because they are also the primary regulators of subacute care, that may lead them away from some of the more intrusive forms of regulation, such as current survey formats, toward more outcome-oriented regulations. This may be simply wishful thinking, but there is some logic in seeing that as a trend.

■ Summary

Subacute care is the fast-growing child of the healthcare industry. Its clothes do not seem to fit. It is developing faster than it can learn the rules by which it should play, and it keeps experimenting with new and different ideas and approaches. New playmates keep appearing on the scene. Its parents—payers, regulators, and policy makers—are trying to keep up with it and, like any parent, are trying to keep it from injuring itself. However, they are finding it difficult to stay ahead of this exciting, but sometimes unruly, child they have created.

Like most children, subacute care will develop into a useful, productive adult of which its parents can be proud. The growth years may be difficult, but the very fact that it is a new industry segment and is ill defined and poorly regulated leaves room for innovation and creativity. The competition from different provider groups and from within those groups is already resulting in some outstanding examples of good care and good management.

Accrediting agencies such as the Joint Commission, CARF International, and NCQA have moved with relative speed to create standards for subacute care and are using measures based primarily on outcomes, as opposed to structure and process measures. Government regulators have not followed suit, at least at this time. They will have to if subacute care is to survive as a distinct and viable segment of the healthcare continuum.

The past several years have been exciting and challenging for all involved with subacute care. The next few years, as we move toward and into the next millennium, promise no less.

Subacute Care Case

This case involves two people. Both have been admitted to subacute care units following stays in an acute hospital. However, they are different in many ways, as is the type of care they receive. They are used here to demonstrate some of the differences in the segment of the continuum known as subacute care.

David is 17 years old. He was injured in an automobile accident several months ago. Suffering multiple fractures and some internal injuries, he has been in a hospital for several weeks. While his initial injuries have largely healed, with the help of several operations, he still faces a long, difficult period of rehabilitation. It is for that rehabilitation, as well as monitoring of his overall condition, that he has been transferred to a subacute care unit.

Joyce is 67. She has a long history of heart trouble and was admitted to the hospital following her last massive heart attack. That attack, coming on top of her already weakened heart condition, has left her in a semicomatose state. Her breathing is assisted by a mechanical ventilator, and she must be fed and medicated intravenously.

The subacute unit to which David was sent is known as a general subacute unit. It is operated by, and in conjunction with, a multilevel nursing facility. Joyce, on the other hand, was admitted to a chronic subacute care unit, operated by the hospital from which she was transferred. The difference between the two units is primarily the conditions they mostly treat and the kinds of staff and equipment needed to do what they each do best.

Both of them began their journey through subacute care with an assessment by multidisciplinary teams from the subacute units to which they were being transferred. Those assessments identified physical, medical, and mental conditions and developed individual care plans designed to best achieve the outcome goals identified for them. Because David appeared to be in need of physical rehabilitation, his assessment team was heavily weighted with therapists of one type or another, while Joyce’s assessment team was much more nursing oriented.

David’s outcome goal is to be able to return to his home and eventually back to school. The assessment team estimates that he will regain nearly all if not all of his previous functional independence. To achieve that, he requires intensive rehabilitation, including physical and occupational therapy. His care team is headed by a physiatrist and will focus on those therapies, although his medical condition will be watched.

Joyce’s prognosis is not nearly as bright. The team assessing her agreed that she is unlikely to ever improve and sets a goal of maintaining her condition as well as possible until her death, something that is not likely to be that far distant. She does not need rehabilitation, although staff in the unit do some maintenance range-of-motion exercises with her to keep her physical condition from deteriorating. She does, however, require much more intensive nursing care and monitoring than does David and will be cared for under the watchful eye of a cardiologist.

Another difference, based on expected outcomes, is that David will receive close follow-up care after he is discharged to his home. He will probably continue some of his therapy on an outpatient basis and will be tested periodically to make sure he has not regressed in his quest for functional independence. Joyce, unfortunately, will not have that option.

While the probable results of their subacute care are expected to be so different, Joyce and David have a common reason for being transferred to those units. Their care needs are too high for them to be treated at lower levels, such as nursing facilities or at home. Yet, they do not need acute hospital care. A secondary, but very important, factor contributing to those transfers is the cost of care. David is covered by a managed care plan to which his parents belong. Joyce is eligible for Medicare. Both reimbursement sources want to give them the best care they can, but at the lowest possible cost.

Thus, these two people in such different situations both find themselves in subacute units, between hospital and nursing facility care levels. It is a kind of care that suits them both well. Until only a few years ago, David would have stayed in the hospital for many months, at an unnecessarily high cost. Joyce might have remained in the hospital also, but because she was unconscious and was going to die anyway, it is more than likely that she would have ended up in a nursing facility unprepared to provide her with the care she should have had.

■ Vocabulary Terms

The following terms are included in this chapter. They are important to the topics and issues discussed herein and should become familiar to readers. Some of the terms are also found in other chapters but may be used in different contexts. They may not be fully defined herein. Thus, readers may wish to seek other, supplementary definitions of them.

care management
care planning
CARF International
case management
case manager
certificate of need (CON)
chronic subacute care

continuous quality improvement

diagnosis-related groups
gatekeeper
general subacute care
interdisciplinary team
long-term transitional subacute care
managed care organizations (MCOs)
National Committee for Quality Assurance (NCQA)

quality assurance and performance improvement (QAPI)

skilled nursing facilities (SNFs)
subacute care
transitional subacute care

■ Discussion Questions

The following questions are presented to assist you in understanding the material covered in this chapter. They tend to be general but lend themselves to detailed answers. The answers to these questions can be found in the chapter.

1.   What are postacute and subacute care?

2.   Where is subacute care provided, and by whom?

3.   What types of services are included in subacute care?

4.   How and why did subacute care develop?

5.   How is subacute care financed?

6.   What regulations apply to subacute care?

7.   What is the difference between care management and case management?

8.   In reference to the case at the end of this chapter, consider the following:

a. How can subacute care meet the needs of such different patients as David and Joyce?

b. Should both be included in a single care category, or should different levels of care be created for them?

c. Is subacute care really a response to patient needs, or is it a way of increasing financing for providers?

NOTE: This question applies to the overall system, but applying it to the case will assist you in seeing the implications for those using the system.

■ References

AHA. (2014). Rehabilitation. Retrieved from American Hospital Association: 

http://www.aha.org/advocacy-issues/postacute/rehab/index.shtml

.

American Hospital Association (AHA). (2010, June). Maximizing the value of post-acute care. Retrieved from 

http://www.aha.org/research/reports/tw/10nov-tw-postacute

.

Anthem. (2013, May 9). Inpatient subacute care. Retrieved from 

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a050124.htm

.

Buxbaum, R. (2009, March). Subacute care: The road ahead. Retrieved from 

http://www.annalsoflongtermcare.com/content/subacute-care-the-road-ahead

.

CA Subacute Care Unit. (2012). Subacute care. Retrieved from 

http://www.dhcs.ca.gov/provgovpart/Pages/SubacuteCare.aspx

.

Centers for Medicare & Medicaid Services (CMS). (2012). Post acute care reform plan. Washington, DC: Centers for Medicare & Medicaid Services. Retrieved from 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/pac_reform_plan_2006

.

Centers for Medicare and Medicaid Services (CMS). (2013, June 5). QAPI description and background. Retrieved from 

http://cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapidefinition.html

.

Dummit, L. (2011, March 28). Medicare’s bundling pilot: Including post-acute care services. Retrieved from 

http://www.nhpf.org/library/issue-briefs/IB841_BundlingPostAcuteCare_03-28-11

.

Griffin, K. (1995). Handbook of Subacute Health Care. Gaithersburg, MD: Aspen Publishers.

Hyatt, L., & Cornish, K. (1997). Regulations to watch for in 1997. Journal of Long-Term Care Administration, pp. 21–23.

MedPac. (2013). A data book: Healthcare spending and the Medicare program, June 2005. Washington, DC: Centers for Medicare & Medicaid Services.

ParentGiving. (2013). What is subacute nursing home care? Retrieved from 

http://www.parentgiving.com/elder-care/skilled-nursing-facility-sub-acute/

.

Singh, D. (2010). Effective management of long-term care facilities (2nd ed.). Sudbury, MA: Jones and Bartlett Learning.

Chapter 5
Subacute and
Postacute Care

Learning Objectives

1. Define and describe subacute
and postacute care

2. Identify where subacute care fits
in the continuum of care

3. Identify sources of financing for
subacute care

Learning Objectives (continued)

4. Identify and describe regulations
affecting subacute care

5. Identify and discuss ethical issues
affecting subacute care

6. Identify trends affecting subacute
care for the near future and the
impact of those trends

What is Postacute Care?

Postacute care:
Improves transition from hospital to

the community
Provides services to patients needing

additional support following
discharge from the hospital

Postacute Care Providers

Include:
 Inpatient rehabilitation facilities
 Long-term care hospitals
 Skilled nursing facilities
 Home health agencies

What is Subacute Care?

 Comprehensive inpatient care
 Comes after, or instead of, acute care
 Between acute and long-term care
 Usually for a defined period of time
 Developed largely for cost savings

Philosophy of Care

Four types:
Transitional
General
Chronic
Long-term transitional

Ownership of Subacute Facilities

Mostly freestanding SNFs (two-thirds)
• Rehabilitation focus

Hospital-based
• Medical focus

Many owned by corporate chains

Services Provided

• Rehabilitation • Chemotherapy

• Physical therapy • Parenteral nutrition

• Occupational therapy • Dialysis

• Respiratory therapy • Pain management

• Cardiac rehabilitation • Complex medical care

• Speech therapy • Wound management

• Postsurgical care• Ventilation care

• Other specialty care

Care Planning

 Focus on quality of care and outcomes
 Initial assessment
 Interdisciplinary team
 Weekly team conferences
 Ongoing evaluation

Case Management

Focus on efficiency, cost-effectiveness
Manage resources to optimize outcomes

at lowest cost
Case managers may be:
• “External” – hired by payer
• “Internal” – hired by provider

Consumers of Subacute Care

 Post hip-replacement surgery
 Spinal cord or brain injuries
 Strokes
 Cancer
 AIDS
 Wounds
 Cardiac recovery
 Respiratory ventilation
 I.V. therapy or feedings

Market Forces

 Cost-saving efforts
 Managed care
 Choice

Regulations

Purpose of regulations:
Care is safe and of high quality
Care is not unnecessarily expensive
Services are uniformly accessible
Rights of workers are protected

Types of Regulations

 Medicare
 OBRA
 Other – similar to other providers

Accreditation

 Joint Commission
 CARF International
 NCQA

Financing Subacute Care

Reimbursement Sources:
Medicare – two-thirds
• Pays as SNF

Other third:
• Managed care
• Medicaid
• Private insurance, self-pay, and other

Staffing

Interdisciplinary team:
 Program administrator
 Physicians
 Nursing
 Other professional staff
 Nonlicensed staff

Legal and Ethical Issues

 Meeting regulations
 Liability issues

Management Qualifications

 Licensed by the states as nursing
facility administrators

 Hospital-based units must find a
licensed administrator or get one of the
hospital administrators licensed

Management Challenges
and Opportunities

 Changing the culture of the
organization

 Balancing cost and quality
 Coordination, competition
 Physical facility considerations

Significant Trends

 Managed care
 Changes in acuity levels
 Emphasis on outcomes

Summary

Subacute care is the newest form of long-term
care, falling between acute and long-term care.

• Slide 1

Learning Objectives
Learning Objectives (continued)
What is Postacute Care?
Postacute Care Providers
What is Subacute Care?
Philosophy of Care
Ownership of Subacute Facilities
Services Provided
Care Planning
Case Management
Consumers of Subacute Care
Market Forces
Regulations
Types of Regulations
Accreditation
Financing Subacute Care
Staffing
Legal and Ethical Issues
Management Qualifications

• Management Challenges and Opportunities

Significant Trends
Summary

Long-Term Care: Managing Across the Continuum, Fourth Edition

John R. Pratt

CHAPTER FIVE: SUBACUTE AND POSTACUTE CARE

CHAPTER HIGHLIGHTS

What is Postacute Care?

· Services to patients needing additional support to assist them to recuperate following discharge from an acute hospital.

What is Subacute Care?

· Comprehensive, cost-effective inpatient level of care for patients who have had an acute event.

What is the Difference between Postacute Care and Subacute Care?

Subacute Care

Post-Acute Care

– May be either after or in place of acute care
– Is after acute care

– Provides in-patient services
– Provides outpatient services

– Provides medical and nursing care
– Provides nursing and/or

non-medical care

Postacute Care

· Provided by:

· Inpatient Rehabilitation Facilities

· Long-Term Care Hospitals (LTCH)

· Skilled Nursing Facilities

· Home Health Agencies

· Use of Postacute Care

· About one-third of hospital patients go on to use postacute care. The most common, single, postacute care destination for beneficiaries discharged from acute inpatient care hospitals is a skilled nursing facility.

· Medicare Conditions of Participation – providers must meet different conditions of participation

· Bundled Payments – Like other Medicare-certified providers, post-acute care providers will be impacted by CMS’s Bundled Payments for Care Improvement initiative.

· Readmissions – The Affordable Care Act of 2010 (ACA) reduces payments to hospitals for greater than expected readmissions, decreasing payments for all Medicare discharges in the prior year.

Subacute Care

How did Subacute Care come to be?

· It is one of the fastest growing segments of the health care delivery system.

· Result of pressures to be cost-effective, increased demand for consumer choice, and competition between providers.

Defining Subacute Care

· Comprehensive inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process.

· Goal oriented treatment rendered immediately after, or instead of, acute hospitalization to treat one or more specific active complex medical conditions or to administer one or more technically complex treatments.

Philosophy of Care

· Specific care rendered for very specific reasons (conditions or treatments)

Ownership of Subacute Care Units

· Often provided by existing hospitals or free-standing nursing facilities.

Services Provided

· May include:

· Rehabilitation

· Physical and Occupational Therapy

· Respiratory Therapy

· Cardiac Rehabilitation

· Speech Therapy

· Postsurgical Care

· Chemotherapy

· Total Parenteral Nutrition

· Dialysis

· Pain

Management

· Complex Medical Care

· Wound Management

· Ventilation Care

· Other Specialty Care

Care Planning

· Involves assessing each individual patient’s needs, developing a care plan to meet those needs, and constantly reviewing the care plan and adjusting it as needed.

Measuring Quality of Care

· There are numerous excellent tools available for measuring outcomes-based effectiveness.

· QAPI is the merger of two complementary approaches to quality, Quality Assurance (QA) and Performance Improvement (PI). Both involve seeking and using information, but they differ in key ways

Case Management

· Its primary goal is the cost-effectiveness of the care given.

Consumers Served

· Patients needing a high level of skilled care, generally with a defined treatment plan and timetable for discharge or transfer to another type of care.

· They need rehabilitation, monitoring, or other specialized treatment.

Market Forces Impacting Subacute Care

· Cost Saving Efforts – the primary impetus for subacute care.

· Managed Care – A key promoter of subacute care.

· Choice – The rising demand by health care consumers for more choice in their care is important.

Regulations

· Subject to most of the same regulations as other providers, but is still an immature provider form.

Accreditation

· Joint Commission – Joint Commission on Accreditation of Healthcare Organizations

· CARF International – Commission on Accreditation of Rehabilitation Facilities

· NCQA – National Committee on Quality Assurance

Financing Subacute Care

· No single payer for subacute services, nor any standardized payment mechanism.

· Most reimbursement comes from Medicare, Medicaid, and managed care organizations.

· Managed care influence is growing, even for public payers.

Staffing/Human Resource Issues

· Interdisciplinary team consisting of:

· Program Administrator

· Physicians

· Nursing

· Other Professional Staff

· Non-Licensed Staff

· Recruitment

Legal/Ethical Issues

· Fall into two general categories:

· Meeting licensure and reimbursement regulations

· Professional liability

Management

Management Qualifications

· Subacute care administrators need the same skills as administrators of other health care organizations.

Management Challenges and Opportunities

· Changing the Culture of the Organization – may be part of a hospital or skilled nursing facility with different culture

· Balancing Cost and Quality – similar to other providers.

· Coordination, Competition with Other Facilities, Organizations – need to work with others to survive.

· Physical Facility Considerations – may have to adapt from another provider type.

Significant Trends and Their Impact on Subacute Care

· Managed Care – a growing influence.

· Changes in Acuity Levels – accepting patients from acute care – or instead of acute care presents certain problems.

· Emphasis on Outcomes – more emphasis than other provider types since patients are there for specific treatments.

PAGE

19

Chapter 5

© 2010 Jones and Bartlett Publishers, LLC