The Continuum of Care

The Pivotal Role of Post-Acute and Long-Term Care in Healthcare Delivery www.chanet.org

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The Continuum of Care

Nation’s healthcare system traditionally defined by acute care The continuum of care spans a lifetime and includes: ◦ Preventive care ◦ Care management ◦ Acute care ◦ Post-acute care ◦ Long-term care

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Post-Acute Care

Care provided to patients who are discharged from an acute-care setting but still require intensive medical treatment Typical Post-Acute Settings ◦ Long-Term Acute Care Hospital ◦ Skilled Nursing Facility ◦ Inpatient Rehabilitation Facility

Long-Term Acute Care Hospital (LTACH)     Care for medically complex patients Average length of stay of 25 days Patients often transferred from ICU Typical services include ◦ Comprehensive rehabilitation ◦ Respiratory therapy ◦ Head trauma treatment ◦ Pain management ◦ Specialized respiratory care for patients requiring mechanical ventilation

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Skilled Nursing Facility (SNF)

Nursing home certified by the Centers for Medicare and Medicaid Services to provide skilled nursing services Aim is to restore patients to previous level of functioning SNF patients most often recovering from: ◦ Hip fracture ◦ Stroke ◦ Pneumonia ◦ Heart Failure

Inpatient Rehabilitation Facility (IRF)

   Post-acute option for patients who need intensive rehabilitation Patients must benefit from 3 hours of therapy everyday 60% of case mix must be patients with specific conditions including: ◦ Stroke ◦ Spinal cord injury ◦ Congenital deformity ◦ Amputation

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Long-Term Care

Assistance for those needing help with “activities of daily living” (ADLs) Serves the elderly as well as others Provided in Various Settings ◦ Home based ◦ Community based ◦ Assisted Living ◦ Nursing Facility

Financing Care on the Continuum

   One year of nursing home care: $68,000 One year of periodic home health visits: $18,000 ◦ ◦ ◦ ◦ Payers of Post-Acute and Long-Term Care Individuals Insurance Medicare Medicaid 22%

Who Pays for Long-Term Care?

11% 42% 25% Medicare Medicaid & Other Public Funds Out-of-Pocket Funds Private Insurance

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Medicare

Federal Program for those 65 and older Covers medical/rehabilitative care in various settings including: ◦ LTACH ◦ SNF ◦ IRF Does NOT cover long-term care

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Medicaid

Joint state and federal program Will pay for long-term care if: ◦ Individual is 65 or older ◦ Has low income and assets ◦ Individual of any age who has a major disabling condition Services can be provided: ◦ In a nursing facility ◦ At home

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Out-of-Pocket

Post-Acute Care: ◦ Individuals may still pay premiums, deductibles and co-insurance associated with Medicare ◦ Medicare coverage for skilled nursing care runs out after 100 days Long-Term Care: ◦ 25% patients pay for care themselves ◦ Medicaid will pay once individuals spend down all of their assets paying for long-term care

LTACHs and Efficiency

Percent of Time Spent on Ambulance Diversion in the Last Year (2007)

20% 58% 9% 13%     Relieve pressure on acute care ICUs and ERs Specialize in specific patient set Improve outcomes for certain patient groups Reduce re hospitalizations No Diversion Time Up to 9.9% of the Time 10-19.9% of the Time 20% or More of Time

SNFs, Long-Term Care and Efficiency

 Skilled Nursing Facilities ◦ Specialize in rehabilitation ◦ Relieve pressure in acute care setting ◦ Ensure acute care treatment benefits are fully realized ◦ Reduce re hospitalizations  Long-Term Care Settings ◦ Provides help with daily living skills necessary for recovery ◦ Ensures medical regimens are followed ◦ Reduce re hospitalizations

Challenges along the Continuum

 ◦ ◦ Workforce shortages ◦ Highest vacancies for certain key workers Negative stereotyping of work environment Wages constrained by low Medicare & Medicaid Reimbursements ◦ Northeast Ohio provides plentiful opportunities for workers, increasing turnover & vacancy rates

Challenges along the Continuum, Cont’d.

  Regulatory Environment ◦ 1 hour skilled care = ½ hour paperwork ◦ Resources diverted away from patient care LTACH 25-percent Threshold Rule ◦ Prohibits LTACHS from accepting more than 25% of patients from one hospital ◦ Adjusts reimbursement downward for all discharges ◦ Includes hospital-within-hospital LTACHs

Suggestions for Stakeholders

     Support quality patient care by advocating only policy changes that promote care, not those that merely add regulatory burden. Include representatives from post-acute and long-term care in policy discussions.

Support policies to bolster the workforce.

Develop strategies that ensure appropriate placement.

Discourage negative perceptions through open and honest dialogue.