How Do We Best Care For the Chronically Critically Ill?

By Sean Muldoon, MD
 Sean R. Muldoon, M.D., M.P.H., F.C.C.P.<br />Senior Vice President and Chief Medical Officer<br />Kindred Healthcare Hospital Division Sean R. Muldoon, M.D., M.P.H., F.C.C.P.
Senior Vice President and Chief Medical Officer
Kindred Healthcare Hospital Division

Many important questions were raised by information published in the June 2012 issue of the journal Respiratory Care. This issue followed a national symposium dedicated to the “chronically critically ill patient,” the patient with ongoing costly medical interventions, risk for medical complications and death, and the need for extensive post-acute care services.

One review article in the journal examined a subset but representative group of chronically critically ill patients, those on prolonged mechanical ventilation or PMV. PMV patients have been somewhat arbitrarily defined as those who require more than 21 days of mechanical ventilation for at least six hours per day. According to published data, it is estimated that between four and 13 percent of mechanically ventilated patients require PMV, and between 7,250 and 11,400 patients are undergoing PMV at any given time. The number of PMV patients is expected to double over the next eight years due to increasing survival of acute events, heroic surgical interventions, and the increased chronic disease burden of the elderly population. New strategies for efficient care of this population are imperative.

PMV patients are cared for in a variety of settings, including acute care facilities, long-term acute care facilities, a few specialized skilled nursing facilities and rehabilitative venues, depending on their acuity, prognosis and local practice patterns. There is little doubt that this patient population represents a substantial cost burden in the current care structure, which includes such a diverse group of venues. In skilled nursing facilities, we know that Medicaid payments are prohibitively low and Medicare payments, while higher than Medicaid, are lower than they are in alternative venues of care, even for the sickest patients. The review article points out that this could lead to “unacceptable rates of readmission” to short-term acute care facilities from skilled nursing facilities.

The diversity of destination venues to which these patients are discharged may be at the root of the issues surrounding the cost of their care. Though these chronically critically ill patients, and specifically the PMV patient population, make up a small percentage of acute care discharges, they are a disproportionately costly group and for this reason the continuation of their care bears further study both from cost and functional standpoints. This is a group that is particularly medically, functionally and psycho-socially vulnerable and these patients are potential candidates for a continued care hospital pilot where the number of patients becomes large enough to study care models, outcomes and costs in order to develop an efficient model of care.

 This figure shows what happens to PMV patients over the first year after they are initially discharged from the hospital. We can see the transitions back and forth between various venues of care, and this graphic makes clear the need for further study of where these patients are going post-hospitalization and why, and whether there are ways we can better streamline their care to make it more effective and cost-efficient. This figure shows what happens to PMV patients over the first year after they are initially discharged from the hospital. We can see the transitions back and forth between various venues of care, and this graphic makes clear the need for further study of where these patients are going post-hospitalization and why, and whether there are ways we can better streamline their care to make it more effective and cost-efficient.

 

References:
Donahoe MP. Current venues of care and related costs for the chronically critically ill. Respiratory Care.<http://www.ncbi.nlm.nih.gov/pubmed?term=current%20venues%20of%20care%20and%20related%20costs%20for%20the%20chronically#> 2012 Jun;57(6):867-86; discussion 886-8.
 

<This figure shows what happens to PMV patients over the first year after they are initially discharged from the hospital. We can see the transitions back and forth between various venues of care, and this graphic makes clear the need for further study of where these patients are going post-hospitalization and why, and whether there are ways we can better streamline their care to make it more effective and cost-efficient.