The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.
Back in the old days, medicine was practiced through home visits. In the early 20th century, as healthcare became institutionalized and medical insurance replaced ‘pay-as-you-go’, home visits became a thing of the past. Today there are a multitude of factors that are giving the practice of home visits a second look, and I think this is a positive development.
Skilled Nursing Facilities (SNFs, often referred to as “sniffs”) provide an added dimension of care that can positively impact important patient metrics, including both length of stay and readmission. The prevention of readmission is receiving increased attention as the Affordable Care Act requires that in 2013, Medicare will penalize hospitals for what it deems as “excess readmission”. As a result, increased attention is being paid to the work in this post acute care setting that can be critical to reducing readmission. Statistics form HCUP (Healthcare Cost and Utilization in the United States) estimate that 13% of all patients are discharged to SNF’s and other long term care facilities. I started working with a SNF in February of this year and have seen up close the continuity of care that is provided.
SNFs are funded by Medicare and the distinction between a SNF and a “non-skilled” nursing facility are services such as occupational therapy, physical therapy, speech therapy, tube feeding, and treatment with antibiotics. There is a greatly improved quality of care when these skilled beds are available to patients. In being able to continue the level of care that would also happen at the hospital, I am able to help patients in and out of the hospital setting, an emerging hospitalist field referred to as “extensivists”.
Health care spending now represents greater than 16% of our Gross Domestic Product, up from 13% in 2000. It is continuing to grow, some say at the rate of 1.5 times GDP. As we approach the 20% benchmark, we need to be concerned that this could cripple our country’s ability to export goods and services and can bankrupt our country unless systematic changes are made. And along with the financial danger comes the subsequent challenge to hospitals to continue to provide the same or better quality of care for more people but with diminished resources. We need to accept the fact that reimbursements will not go up, and that the only way to prosper will be through increased efficiency.
The integration and collaboration of hospitals with their physicians and outpatient referral sources triggered by new health care legislation are leading to a paradigm shift in health care—a change that can help with the challenges of the future. For example, with bundled payments, many will be paid in lump sums which could lead to more sharing of responsibility. In this way, bundled payments can not only streamline the cost of healthcare but can also help to improve efficiency and quality of care.
Observation medicine is going to fill a large and growing portion of hospital beds in the near future. Whether or not the government takes over healthcare, one way that costs will be cut will be to apply more, more specific and stricter clinical criteria in order to "qualify" a patient for an inpatient admission. This, of course, won't change the absolute number of patients that we just can't send home. The patients who aren’t admitted but who can’t be released will often end up placed in observation. In addition, if plans are implemented to deny payment for certain patients who return within 30 days of discharge, a good number of those folks who show up again within the 30 day window will end up in observation.
Until this spring, patients placed in observation at our hospital, Banner Del Webb Medical Center, were boarded with the general inpatient population, and were cared for by the same group of internists and hospitalists as the inpatients. This inevitably led to increased lengths of stay, since, even though the observation patients were less sick, the admitting doctors still ordered lots of consults, tests and scans with no urgency in getting them completed or in rounding and discharging.
One of the provisions of the Patient Protection and Affordable Care Act has not gotten much play outside of the world of emergency medicine. It was designed to prevent health plans that fall under this act from sticking it to patients who have a medical or traumatic emergency and are treated by an out of network provider.
There are two elements to this protection: 1) a requirement that the plan set a benefit that is ‘reasonable’, and 2) that the coinsurance percentage and any copay amount that might apply to emergency care be no greater than would apply if the patient had been treated by an in-network provider. This is because, in an emergency, patients may not be able to select an in-network provider to treat them, even if they go to an in-network hospital.
Although the second protection is fairly straight forward; the first protection is a bit tricky, because one person’s ‘reasonable’ is another’s ‘outlandish’ and someone else’s ‘grossly inadequate’. CMS attempted to define ‘reasonable’ for this provision in the regs by requiring plans to determine which of the following three standard results in the greatest benefit:
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It was a lot of fun to do, and we are repeating it again this week. Im sure
Your cosigner assumes joint liability for you paying back the advance, and all
Tragically, arriving requires paying critical educational cost expenses, and
Hmmmm, who ever would have thought poker in the ED could become a best
In any case, the way toward figuring out who does and does not get an advance