Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Attending to the Care in Healthcare

10/11/2012 10:23:05 PM | 2 comments

As the healthcare system is changing shape, and departments are realigning with the goal of increasing efficiency and care coordination, I hope that the big picture idea of the nature and purpose of healthcare does not get left behind.  What is the value of human life?  And how does this fit into the massive changes taking place in the organization and delivery of services?

At times, insurance companies and others try to estimate the value of human life for the purposes of cost/benefit discussions. Of course, this is an impossible task, as no one can assign a monetary value to a person’s life. Similarly, it is impossible to price out patients’ pain and emotional distress, or the ordeal suffered by their loved ones. But while I realize that businesses need to look at the bottom line, I hope that business decision makers realize that often the humanitarian perspective can benefit the bottom line. I hope that as the pressures mount and the Acute Care Continuum is forming, there is still time and a place for providers to ask, “What if this patient were my mother?”

For example, let’s look at the question of hospital readmissions.  Hospitals are now being penalized for excessive readmissions. Medicare is going to penalize 2,217 hospitals for readmission, and these hospitals will pay about $280 million. And yet my father in law, who had stated that it was important for him to die at home with his loved ones, was shuttled multiple times in his final months between a skilled nursing facility (SNF) and a hospital, racking up a large number of hospital readmissions, and finally passing away in a SNF.  Ironically and sadly, the readmission penalties established by the ACA would have worked to everyone’s benefit if he had simply been asked the appropriate questions.  He would have refused the repeated hospital admissions, thus avoiding penalties for the hospital and also allowing himself  to die in the environment he chose—his own home

If hospitals were able to design the optimum system for care, what would it look like?  First, I think providers would be financially rewarded for quality of care as opposed to quantity, as has already been started by the ACA.  Adverse safety events in the hospital can lead to longer stays and corrective treatments, as well as to deaths and readmissions.  Adverse events, which can be consequences of short sighted cost savings measures, cost money!  While designing environments to insure patient safety can entail costs, in the longer-term, doing so benefits both the business and the patient.  

Patients’ preferences would also be taken into account for treatment planning.  Like my father in law, patients’ choices may actually save money for the health care system. For example, sometimes less radiation could be better, and this might be the patient’s choice. But currently, with the system as chaotic and reactive as it is, there is little option to ask patients what they prefer. So patients are overtreated, both to their detriment, and to the detriment of the bottom line.

While CMS and the ACA can lead the way on this one with financial incentives, we must lead the way on ethics.  EMTALA certainly is the right start when it comes to the ethics of treating sick people, but once patients are in the system, I hope that the dizzying speed of change does not make it more difficult for providers to take a long-term view and to concern themselves with the mission of healthcare and not just the business of healthcare. Within a longer term perspective, ethical, humanitarian treatment is compatible with sensible business practice.



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Perspectives on the Acute Care Continuum
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By Thomas Lukaszczyk, MD, FACEP
Over the years I have seen big changes in our practice of emergency medicine. I remember the first time I heard about an emergency physician down in the San Diego desert who treated his ED patients in the hallways, the... ...
1/3/2013 12:47:56 AM

Bonnie
Interesting and thoughful blog. If we are trained to "first do no harm" we have an obligation to ask the patient what they want. Clearly in this instance the patient would have had what he wanted and the hospital would have had what they wanted.
10/19/2012 3:39:31 AM