Post-acute care (PAC) refers to care, including rehabilitation or palliative services, that patients receive after, or in some cases instead of, a stay in an acute care hospital. Depending on the intensity of care required, patient treatment may include a stay in a skilled nursing, long-term care or inpatient rehabilitation facility; ongoing outpatient therapy; or care provided at home. Importantly, these services are also used prior to a hospital admission or, as stated above, in lieu of a hospitalization.

  • Skilled Nursing Facility – Skilled nursing facilities (SNFs) provide short-term skilled nursing and rehabilitation services to patients after a stay in an acute care hospital.  SNFs  are the most commonly used PAC service.
  • Home Health Services – Home health agencies (HHAs) provide services to patients who are homebound and need skilled nursing or therapy.
  • Inpatient/Outpatient Rehabilitation (IRF) – Inpatient rehabilitation facilities (IRFs) provide intensive rehabilitation services to patients after an illness, injury, or surgery. Rehabilitation programs at IRFs are supervised by rehabilitation physicians and include services such as physical and occupational therapy, rehabilitation nursing, speech–language pathology, and prosthetic and orthotic services.
  • Home Infusion – Home infusion services provide infusible medications and the required nursing and monitoring for patients in their home.  The home infusion team consists of nurses and pharmacists, and may include the use of a certified home health agency.
  • Palliative care – Palliative care is specialized medical care for people with serious illness, focused on providing relief from the resulting symptoms and stress. The goal is to improve quality of life for both the patient and the family.  Palliative care is provided by a specially-trained team of physicians , nurses and other specialists who work together with a patient’s other physicians to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness, and can be provided along with curative treatment. Palliative care can be provided in both inpatient and outpatient settings.
  • Hospice – Hospice is a special concept of care designed to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments. The goal of hospice care is to improve the quality of a patient’s last days by offering comfort and dignity. Hospice care is provided by a team-oriented group of specially trained professionals, volunteers and family members.

    Hospice addresses all symptoms of a disease, with a special emphasis on controlling a patient’s pain and discomfort.  Hospice services can be provided in the patient’s home or a designated facility.

  • Long Term Care/Memory Care -Long-term care (LTC) encompasses a variety of services which help meet both the medical and non-medical needs of people with a chronic illness or disability who cannot care for themselves for long periods of time.  Many LTCs also incorporate specialized services for patients experiencing dementia from diseases such as Alzheimer’s.  The goal of care is to provide support in a safe environment that allows the patient to maintain as much cognitive and functional status as possible.

As healthcare payment methodologies change from volume to value, healthcare systems are being held accountable for the cost and quality of care across the continuum. Historically, each provider was accountable only for the outcomes generated directly from the care they provided.  It is now time to realize the cost and quality benefits that can be gained by providing consistent, effective utilization of post-acute services.

Historically, the focus of healthcare costs has been on care provided in the hospital (acute care). Although often necessary and appropriate, acute care is the highest utilizer of the healthcare dollar overall, accounting for over 30 cents of every dollar spent. With the focus on moving from volume-to value-based payments, there is an increased need to focus on incorporating post-acute services that foster quality while reducing the overall cost of care.

Post-acute services generally cost less and have demonstrated similar, if not improved, patient outcomes compared to hospital care. To improve reimbursement in the value-based world, it is necessary to assure the right patient is going to the right site of care at the right time. Healthcare systems that have been successful in the early move into value-based care have developed processes that provide “systemness” in post-acute service utilization.

Medicare covers up to 100 days of SNF care per spell of illness after a medically necessary inpatient hospital stay of at least 3 days. For beneficiaries who qualify for a covered stay, Medicare pays 100 percent of the payment for the first 20 days of care. Beginning with day 21, beneficiaries are responsible for copayments. For 2017, the copayment is $164.50 per day. Medicaid and most commercial insurers also cover SNF stays.

Medicare uses a prospective payment system (PPS) to pay SNFs for each day of service. Information gathered from a standardized patient assessment instrument—the Minimum Data Set—is used to classify patients into case-mix categories called resource utilization groups (RUGs). RUGs differ depending on the services SNFs provide to a patient (such as the amount and type of rehabilitation therapy and the use of respiratory therapy and specialized feeding), the patient’s clinical condition (such as whether the patient has pneumonia), and the patient’s need for assistance in performing activities of daily living (ADLs).

Medicare home health care consists of skilled nursing, physical therapy, occupational therapy, speech therapy, aide services, and medical social work provided to beneficiaries in their homes. To be eligible for Medicare’s home health benefit, beneficiaries must need intermittent (fewer than eight hours per day) skilled care to treat their illnesses or injuries and must be unable to leave their homes without considerable effort. Medicare requires that a physician certify a patient’s eligibility for home health care and that a patient receiving services be under the care of a physician. In contrast to coverage for skilled nursing facility services, Medicare does not require a preceding hospital stay to qualify for home health care. Also, unlike for most services, Medicare does not require copayments or a deductible for home health services.

Medicare pays for home health care in 60-day episodes. Payments for an episode are adjusted for patient severity based on patients’ clinical and functional characteristics and the number of therapy visits provided. If beneficiaries need additional covered home health services at the end of the initial 60-day episode, another episode commences and Medicare pays for an additional episode.

For an IRF claim to be considered reasonable and necessary, the patient must be reasonably expected to meet the following requirements at admission:

  • The patient requires active and ongoing therapy in at least two modalities, one of which must be physical or occupational therapy.
  • The patient can actively participate in and benefit from intensive therapy that most typically consists of three hours of therapy a day at least five days a week.
  • The patient is sufficiently stable at the time of admission to actively participate in the intensive rehabilitation program.
  • The patient requires supervision by a rehabilitation physician. This requirement is satisfied by physician face-to-face visits with a patient at least three days a week.

Since January 2002, Medicare has paid IRFs under a per discharge prospective payment system (PPS). Under the IRF PPS, Medicare patients are assigned to case-mix groups (CMGs) based on the patient’s primary reason for inpatient rehabilitation, age, and level of motor and cognitive function. Within each of these CMGs, patients are further categorized into one of four tiers based on the presence of specific comorbidities shown to increase the cost of care. Each CMG tier has a designated weight that reflects the average relative costliness of cases in the group compared with that of the average Medicare IRF case. he CMG weight is multiplied by a base payment rate and adjusted to reflect geographic differences in the wages IRFs pay. The payment is further adjusted based on the IRF’s share of low-income patients. Additional adjustments are made for IRFs that are teaching facilities and for IRFs located in rural areas.

The inpatient rehabilitation facility (IRF) compliance threshold requires that no less than 60 percent of all patients (Medicare and other) admitted to an IRF have as a primary diagnosis or comorbidity at least 1 of 13 conditions specified by CMS.

Measuring quality across the care continuum today is difficult. The CMS measures quality differently among the different types of post-acute care. Currently only skilled nursing facilities, home health agencies, and hospice are measured and benchmarked by CMS. In addition, post-acute services are not included in a number of CMS programs to adopt and modernize electronic health records (EHRs). Limited data about what happens at facilities makes comparison across facilities difficult.

In the face of these barriers, some forward-looking health systems are working with post-acute care facilities to create their own quality metrics, share data, and steer patients to certain facilities based on aligned goals, clinical need, quality, and outcomes.

Regarding skilled nursing facility (SNF) quality, the Commission examines risk-adjusted rates of readmission to the hospital, discharge back to the community, and change in functional status during the SNF stay.

Regarding HHA quality, the rate of hospitalization and patient improvement in walking and transferring are considered.

Inpatient rehabilitation facilities are measured on three broad categories of IRF quality indicators: risk-adjusted facility-level change in functional and cognitive status during the IRF stay, rates of discharge to the community and to SNFs, and rates of readmission to the acute care hospital.

Hospice services are measure more on process measures than on patient outcomes.

Measure 1:  Patients Treated with an Opioid who are Given a Bowel Regimen

Percentage of patient stays treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed.

Measure 2:  Pain Screening

Percentage of patient stays during which the patient was screened for pain during the initial nursing assessment.

Measure 3:  Pain Assessment

Percentage of patient stays during which the patient screened positive for pain and received a comprehensive assessment of pain within 1 day of the screening.

Measure 4:  Treatment Preferences

Percentage of patient stays with chart documentation that the hospice discussed (or attempted to discuss) preferences for life sustaining treatments.

Measure 5:  Beliefs/Values Addressed (if desired by the patient)

Percentage of patient stays with documentation of a discussion of spiritual/religious concerns or documentation that the patient and/or caregiver did not want to discuss spiritual/religious concern

Measure 6:   Hospice Visits when Death is Imminent

This measure covers two assessments related to hospice staff visits to patients at the end of life.

Measure 1: Percentage of patients receiving at least one visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life.

Measure 2: Percentage of patients receiving at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses or hospice aides in the last 7 days of life.

Measure 7 : Hospice and Palliative Care Composite Process Measure – Comprehensive Assessment at Admission

Percentage of patient stays during which the patient received all care processes captured by quality measures

  • Post-acute services are generally not integrated into healthcare delivery models
    • Post-acute service utilization is typically directed by referral based relationships, driven by payers and rotation referral panels
    • There is a great deal of variation in outcomes and cost amongst post-acute providers and hospital utilization
    • Limited coordination between ancillary providers results in a differing patient experience
    • No ability to share medical records
    • Transitions of care are not standardized

Although, seemingly easy, assessing utilization of post-acute services and the associated outcomes can be difficult. Even within one health system there may be variation. When someone requires rehabilitation or additional services after a hospital stay, there currently is little rhyme or reason as to why a patient is discharged to a skilled nursing facility (SNF), home health agency, inpatient rehabilitation facility, or long-term acute care hospital. It may be a choice based on convenience to the patient’s home, what the patient is familiar with, or just the hospital discharge planner’s or other clinician’s preferences. CMS’s oversight of assuring patient choice in these referrals has also led to increased variation.

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