Tips on How to Recognize Your Patient Needs Post-Acute Care in a Specialty Hospital

By Sean Muldoon, Chief Medical Officer, Kindred Healthcare

Long-term acute care (LTAC) hospitals deliver care for the most difficult to treat, critically ill and medically complex patients – such as patients with respiratory failure, septicemia, traumatic injuries, wounds, or other severe illnesses complicated by multiple chronic conditions.

The LTAC level of care, and an early assessment by a post-acute care representative, may provide care management solutions for referring hospitals and can have a positive impact on patient outcomes.

Changes in Payment Criteria

As a result of the Pathway for SGR Reform Act of 2013, beginning in 2015, the Centers for Medicare and Medicare Services (CMS) implemented payment criteria for LTAC hospital stays to ensure that appropriate patients are admitted to LTACs and to appropriately align payments with patient care costs.

As a result of the payment criteria, there are two distinct levels of reimbursement:

  • Post-Intensive Care (PIC) - patients who most recently spent three or more days in an Intensive Care Unit or require prolonged dependence on a ventilator, and
  • Complex Medical (or site neutral) – all other patients that can benefit from LTAC hospital-level specialized care, but do not meet the PIC criteria.

By establishing these specific thresholds, short-term hospitals have the option to discharge ICU/CCU and ventilator patients to LTAC hospitals at a time when they can best benefit from this level of care. This provides new solutions for hospitals and physicians to consider discharge to a LTAC hospital as soon as it is determined that a patient will need longer acute care.

Chart text: CMS Levels of Reimbursement - Post-intensive care 3+ days in ICU or Complex Medical Patients who require specialized care for extended time

Benefits of Early Post-Acute Care Assessment

During a stay in an ICU, the critical care team can generally tell if a patient will need extended care around days 3-7 of the stay. As stated by CHEST, “While acknowledging that liberation from mechanical ventilation can be unpredictable, but recognizing that by as early as day 7, the need for a prolonged course is likely, a large Prolonged Mechanical Ventilation (PMV) Consensus Conference made the formal recommendation that clinicians “begin consideration for PMV-focused care when tracheostomy is first considered.”1 As soon as it is determined a patient will need longer acute care, it is important for the clinical team to reach out to post-acute representatives to determine the best options or site of care a longer recovery process.

Post ICU/CCU-level patients often require the specialized, interdisciplinary care that is only available in LTAC hospitals. This is because these patients are significantly sicker – with a much higher case mix index – than their acute hospital counterparts.

Once it is determined that an ICU/CCU patient will require prolonged care for a full recovery, it is important that discharge from the unit to the most appropriate level of care not be delayed as patients who experience a delay may experience adverse outcomes.

Early assessments by post-acute networks provide benefit to the patient and referring hospital:

  • Improved patient experience through a smoother transition between facilities; better coordination, less disruptive
  • Enhanced efficiency in case management – earlier identification that the care needs are exceeding the short term facility; potential to help in denial management

LTACs Drive Strong Patient Outcomes

LTAC hospitals have long been recognized for their strong performance in successfully weaning patients off of ventilators. Additionally, recent research looking at non-ventilator patient populations found that for patients with three or more days in intensive care in a short term hospital, LTAC hospital care “is associated with improved mortality and lower payments.”2  The study also concluded that the effects of LTAC hospital care tend to “be more favorable for patients with either multiple organ failure or ≥3 days in an ICU/CCU as compared with patients without these characteristics.”3

Chart text: for ventilated and non-ventilated patients with 3+ days in the ICU, LTAC care is associated with improved mortality and lower payments

Capabilities of Treating High Acuity Patients

Unlike other post-acute settings, LTAC hospitals, which are licensed, certified and accredited as an acute-care hospital, treat patients that have ongoing acute medical needs. Patients benefitting from this elevated level of care are among the hardest to treat patients, often with major complications or multiple chronic conditions in addition to their acute care needs. LTAC hospitals specialize in treating critically ill patients, including those dependent on ventilators for life support, patients with complex wounds, and patients with multiple organ system failure who require extended treatment in a hospital setting.

While LTAC hospitals can successfully treat a wide-range of difficult to treat patients who require a prolonged recovery, 66 percent of the patients treated in 2015 were in 25 diagnosis related groups (DRGs). That same year, nine of the top 25 DRGs were respiratory conditions or involved prolonged mechanical ventilation. In fact, the most frequent diagnosis in LTACs in 2015 was pulmonary edema and respiratory failure4.

Given the LTAC hospital’s unique ability to treat post-ICU and ventilator-dependent patients, CMS and Congress affirmed the value of this specialized care through passage and implementation of LTAC hospital patient payment criteria. However, the criteria also recognizes the value of LTAC hospital care for other medically complex patients to benefit from the specialized care delivered in these hospitals without needing to meet the 25-day average length of stay.

How Kindred Can Help

Kindred LTAC hospitals, also known as Transitional Care Hospitals, provide expert interdisciplinary care to meet the unique needs of each patient who can benefit from our level of care. Treatment is led by physician specialists, and supported by a full complement of disciplines. Additionally, the hospitals feature ICU-level units, telemetry units with on-site laboratory, radiology services and operating rooms. The comprehensive team approach with condition-specific clinical programs assures appropriate lengths of stay and facilitates improved outcomes and a greater chance of recovery.

Kindred Hospitals have an average length of stay of 29 days5  and have a 30-day readmission rate of just 8%6, providing new strategies for referring hospitals to manage readmissions and effective care management. Additionally, our physician-led, interdisciplinary teams have a strong reputation for successfully weaning patients off mechanical ventilation.

As part of determining the most appropriate site from prolonged acute care, our Clinical Liaisons can provide patient assessments, will help physicians and other attending clinicians determine if a patient is appropriate for LTAC hospital services.

If you have a patient who needs more time to recover, contact us and we will help determine if LTAC care is the most appropriate next step.


References:
  1. Management of Patients Requiring Prolonged Mechanical Ventilation; Report of a NAMDRC Consensus Conference. CHEST 2005;128: 3937-3954.
  2. Koenig, L., Demiralp, B., Saavoss, J., & Zhang, Q. (2015). The Role of Long-term Acute Care Hospitals in Treating the Critically Ill and Medically Complex: An Analysis of Nonventilator Patients. Medical Care, 53(7), 582–590. http://doi.org/10.1097/MLR.0000000000000382
  3. ibid
  4. Databook, Medicare Payment Advisory Commission (MedPAC), June 2017
  5. Quality and Innovation Report, Kindred Healthcare, 2017 outcomes
  6. ibid
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