Discussion Topic Before starting this forum, please refer to pages 138-140 in our text. Our text lists some staffing and huma

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.

■ 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.

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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?

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