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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?

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 …

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