Acute care nurses use just about all the skills you can imagine to care for these patients. We believe that we were privileged to see examples of facilities in this segment that are indeed striving to and in many ways achieving many of the goals of the new subacute care movement. For example, the American Health Care Association includes "efficient and effective utilization of health care resources" in its short definition of subacute care. In the ideal, subacute care is more than any type of care provided to those and other patients. Those elements of care are inherently attractive. These generally include physical plant features such as a distinct unit (highly recommended by the National Subacute Care Association [NSCA]), and more and better trained staff (than a "traditional" NF), especially physicians and nurses. We found that: Outcomes are one aspect of quality. Subacute facilities vary in contracting out versus providing in-house therapies and physician services. As a consequence of the lack of congruence between certification and subacute boundaries, key national data bases provide limited useful information about subacute care. Subacute Care Model Organizations that follow the subacute care model serve patients who need moderate- to low-level subacute services such as orthopedic rehabilitation. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has established general accreditation standards for subacute care. Sub-acute care provides continuity of care for patients who no longer require hospitalization, but still need skilled medical care in a rehabilitation facility. Rehabilitation hospitals and units may have difficulty serving subacute patients and still meet the requirement that 75 percent of patients fall within 10 diagnostic categories. The lower number may be a reasonable estimate of subacute care in the first sense of "higher acuity" patients, but both figures substantially overcount the actual volume of subacute care under the second definition. ACUTE REHABILITATION NURSE. Facility-based (institutional) subacute care providers, particularly skilled nursing facilities, have been a driving factor in the development of the subacute care phenomenon. While monitoring quality is costly, the current emphasis on outcomes measurement in this industry might indeed provide strong and effective incentives for continuous quality improvements. A general hospital setting may not be the best place to receive the rehabilitation a patient needs. Large chains are generally better positioned to develop subacute care programs based on their ability to access capital markets, achieve economies of scale and operating efficiency, develop integrated post-acute networks, hire specialized staff, and provide higher margin ancillaries through their own related organizations. High tech home health care firms differ from SNFs in some of their staffing and patient characteristics. Patients admitted to subacute care usually are not ready for a strenuous rehabilitation program. However, the majority of nursing associations with which we spoke had concerns about the whether SNFs were staffed appropriately for the acuity of patients being referred and the quality of care provided. Variations in the Use of the Term Subacute Care C. Concepts Commonly Applied to the Term Subacute Care III. What Services are Identified with Subacute Care? Most subacute patients are discharged home. Of the providers who do collect outcome data, the data measure most often used is limited to rehabilitation subacute and it does not adjust for medical severity. We found that the term subacute care has come to have two meanings, and that understanding those differences is critical to understanding the entire subacute care phenomenon. Some key examples of the undeveloped product include the following: None of the hospital-based SNFs and only a few of the freestanding SNFs we visited are actually using even those clinical outcomes measures (i.e., the FIM) that are currently available; Few of the state-of-the-art facilities we visited could easily produce minimal data (e.g., length-of-stay by patient characteristic or program type) for the patients they called subacute. INTRODUCTION II. What is subacute care? The primary financial and organizational factors shaping the development of subacute care nationally include the efforts of managed care providers to find more cost-effective types of care, the implementation of new Medicare payment policies applicable to acute and post acute care providers, and changes in patient preferences. Second, we found subacute care providers that are successfully applying elements of this concept. In one study, researchers found significant differences in a measure of "applied self care" with hospital patients having significantly greater independence. We had assumed that we would find low hospital use rates in areas with high managed care penetration, but we found that three out of the four market areas have hospital use rates close to the national average and much higher than the managed care "ideal." How is Subacute Care Defined in the Literature? Yet, in other cases providers of different types were engaged in joint ventures and other cooperative activities. However, California is reviewing its CON policies, and new regulations may have an effect on any further development of subacute care. However, some argue that acute care actually occurs in three stages: emergency care (if needed), immediate care (0-12 hours), and transition care (12 hours to 4 days). D. What Do We Know About the Providers of Su… For a patient to qualify for inpatient rehabilitation they must be able to tolerate 3 hours of therapy per day (speech-language pathology, occupational therapy, physical therapy) at least 5 days per week. Medicare is the dominant payor of subacute care. In contrast, the high-end estimate of 8.1 million patient days includes long-term hospitals, but does not exclude patients who require fewer than three hours of nursing care or rehabilitation per day (Ting, 1995), and thus may include some traditional NF patients who are excluded in virtually all formal definitions of subacute care. In addition, Medicare managed care plans who offer expanded hospital benefits to attract beneficiaries have incentives to shift beneficiaries to SNFs to reduce their risk. Following a short introductory chapter (CHAPTER ONE) the results of the study are presented in six chapters described below. Many translated example sentences containing "subacute care" – French-English dictionary and search engine for French translations. More importantly, the number of persons age 85 and older (those who consume the greatest amount of health care) is expected to grow from 3.3 million in 1990 to 6.7 million in 2020. Subacute systemic toxicity is defined as adverse effects occurring after multiple or continuous exposure between 24 h and 28 days. To a large extent, these are the same patients who in the not-very-distant past, were called "Medicare high-end skilled," or simply, "heavy care skilled" patients. When you experience acute pain, you need immediate medical attention. Other outcome measures for medical subacute care are in various stages of development and implementation. The types of conditions treated in different types of subacute care facilities are grossly similar; the severity of illness appeared to vary. The Functional Independence Measure (FIM) is the best known measure for assessing outcomes for rehabilitation patients and is being used to measure subacute rehabilitation outcomes. Career Objectives. The role of home health care in the subacute care industry is the subject of much debate. The exact degree of physician and licensed nurse involvement required is a matter of some debate, particularly since increasing the involvement of highly-trained staff increases costs. Physicians' attitudes about nursing homes may make it more difficult for SNFs to develop subacute programs relative to other post-acute providers. These physiological responses may reach gr… Case management and tracking, physician involvement, and discharge planning for subacute care patients vary across health plans. How are Subacute Care Services Categorized? The reimbursement of subacute care providers (PPS-exempt hospitals or distinct part units, SNFs, and home health agencies) on a facility-specific, cost-related basis, combined with strong incentives for discharge from acute hospitals under PPS has led to both the strong demand for post-acute care services and an increasing supply of post-acute care providers. During recuperation, patients receive rehabilitation in a skilled nursing facility, where they stay overnight until therapy goals are met. Unless these assumptions proved true, simply moving patients to SNFs could be more costly to Medicare than the current situation. In a third study, researchers found that hospital patients scored higher on functional independence at discharge and in change scores than SNF patients. Functional gains were virtually identical, though those treated in SNFs were admitted with lower scores on average. The observation of a general reluctance of physicians to visit patients in SNFs disputes the common claim that subacute care is physician-directed. Thus, when we asked for something like the average length of stay of subacute patients, many providers could readily produce statistics for all Medicare patients, but (even when they agreed that all their Medicare patients were not "truly" subacute patients) either had to do extra work to develop statistics or were unable to provide data exclusively on subacute patients in a subacute program. Few facilities currently are collecting data on quality or clinical outcomes. The Commission of Accreditation of Rehabilitation Facilities (CARF) has established two specific levels of accreditation for inpatient care specifically designed to apply to subacute care. There is nothing new about SNFs, long-term care hospitals, or rehabilitation facilities caring for the types of patients noted above, except perhaps that such patients (particularly those at the highest level of acuity) may constitute a larger proportion of patients in today's SNFs. Medicare's payment systems for acute care have led to increased demand for post-acute care services for higher acuity patients. However, in general few physicians follow their patients into a subacute facility after an acute care stay. The four institutional provider types or "platforms" we studied were nursing facilities (freestanding and hospital-based), rehabilitation hospitals, distinct-part rehabilitation units, and long-term hospitals. Organizations that provide care for persons with AIDS or cancer typ­ ically adopt this model. A small but growing number of SNFs are being accredited by CARF and JCAHO as subacute facilities. For example, a patient requiring ventilator treatment and coma stimulation would cost more than $1,000 per day in a rehabilitation unit of a hospital. Accreditation is likely to be of growing importance in the development of subacute care, but current standards appear to allow a wide range of quality and services under the "accredited" stamp of approval. But, we also found substantial evidence of a movement to create a new type of program to service those patients, a new approach to care, different from traditional Medicare "high-end" skilled care. CHAPTER FOUR examines the state-of-the-art in subacute care based on our site visits at 19 facility-based subacute care providers, telephone interviews with four representatives of three national firms specializing in home infusion therapy (so-called "high tech") home health care, six representatives of five "full-service" home health agencies (HHAs), discharge planners, managed care planners, managed care groups, physicians, patient care advocates, state nursing home associations, state hospital associations, state nurses associations, and state Medicaid officials. Many patients with acute illness or injury require comprehensive care that includes frequent assessments and procedures to manage their condition. Nevertheless, reflecting both on what we saw in the field and have observed in the industry press and other literature, it is clear that much that is called "subacute care" is really just a new name for higher acuity, medically complex patients and/or those requiring more intensive therapies. They must also have a need that must be performed by a skilled, licensed professional on a daily basis. Examples are complex wound care and rehabilitation when a patient can not tolerate 3 hours of therapy a day. Adult subacute care providers should continue to use the appropriate accommodation codes and will receive reimbursement on a per diem basis. Available 8:30 a.m.–5:00 p.m. CONTINUE SCROLLING OR CLICK HERE FOR RELATED SLIDESHOW. Acute Rehabilitation Nurse Resume Example Resume Score: 65%. Video also available at: http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/longtermcare/video/ B. At a minimum, policymakers require reliable answers to two questions. We did not begin the exploration with a fixed notion of subacute care and go forth to count the providers who complied. We compared these provider types in terms of their different payment incentives, regulations, program capabilities and staffing levels, and distinct cultures. For example, in Boston a large portion of hospital-based SNF beds are managed by a corporation that owns a substantial share of the freestanding SNF beds. One patient may need labs drawn, an IV placed for fluids, and an assessment every hour, while another patient is coding and needing CPR with a rapid response team to bring them back to life. Finally, we found critical gaps in information needed by both the public and private sectors. Care techniques in the ideal also include the use of "care maps" and/or critical pathway protocols, program evaluation based on measure outcomes, and an emphasis on continuous quality improvement. As is now widely understood, without some changes made to the current system, Medicare expenditures for post-acute care and for acute care are expected to rise substantially as both the number and proportion of persons over age 65 grows. The same conditions of participation apply to both subacute and skilled nursing facilities. These traditional HHAs are said to receive substantial numbers of discharges from subacute facilities, but we were unable to verify this reported trend. NFs in Los Angeles have the lowest occupancy of the four market areas, and California Medicaid NF reimbursement is the only one of the four applicable systems that provides no additional Medicaid dollars to facilities that take patients with heavier care needs, except for technology-dependent patients. Subacute care techniques in the ideal also include the use of critical pathway protocols, and clinical and program evaluation based on measured outcomes. The Prospective Payment System (PPS) reimburses hospitals on flat rate by diagnosis and provides hospitals with strong financial incentives to discharge Medicare patients as quickly as possible. The development and use of outcomes measures are influencing the market for subacute services by becoming an increasingly important component of subacute care programs. subacute care. We found that the financial pressure of capitation is another factor that results in increased demand for subacute care. Regulatory barriers including CON requirements and enforcement have a direct impact on the development of subacute care. Emergency interventions and services should be integrated with primary care and public health measures to complete and strengthen health systems. But industry leaders do mean something more, and more is expected if subacute care is to be something other than "old wine in new bottles.". 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