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Following acute treatment of injury or illness, many patients require continued medical care, either at home or in a specialized facility. Postacute care refers to a range of such medical, nursing and rehabilitation services that support the individual’s continued recuperation and rehabilitation from illnesses or management of a chronic illness or disability.
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Medicare’s payment to postacute care facilities totaled $59 billion in 2014, more than double since 2001. Also, variation in postacute care is the leading driver for overall Medicare cost. Postacute care providers include three facility based providers: (1) inpatient rehabilitation facilities (IRFs); (2) long-term care hospitals (LTCHs); (3) skilled nursing facilities (SNFs); as well as home based providers, such as home health agencies (HHAs) and hospice. More than 40% of the fee-for-service Medicare beneficiaries received postacute care services after being discharged from an acute care hospital in 2013.
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The Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 requires a standardized patient assessment data to be reported by all postacute care providers. In addition, there is significant work accomplished by Medicare policymakers to create a unified postacute care prospective payment system (PAC PPS) due to:
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four separate payment systems for SNFs, IRFs, LTCHs and HHAs;
similar services provided in all settings with significant payment differences;
the evidence that placement is driven at times by nonclinical factors such as provider availability;
significant unexplained variations in postacute care services;
the paucity of evidence on where the best care is provided.
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One of the first steps to site-neutral payment is being implemented in LTCH setting since late 2015. Traditionally, the selection of appropriate postacute care setting and provider was determined by the hospital care managers/discharge planners. However in light of the increasing complexity of patients and rapidly changing postacute care regulations, it is important for hospitalists to be familiar with the options of multiple postacute care sites as well as the capabilities and types of patients different postacute settings care for. Additionally, due to the need for continuity of care and focus on safe transitions, 30% of the hospitalist groups are now practicing in postacute care settings.
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The Centers for Medicare & Medicaid has identified 30-day readmission rate as a quality indicator across the nation. There is emerging evidence indicating that the 30-day readmission rates range from 5.8% to 19% among postacute rehabilitation facilities among Medicare beneficiaries. We will describe the different types of rehabilitation/postacute care options (see Table 68-1 for types of post-acute care options) followed by strategies for selecting the right setting for hospitalized patients (see Figure 68-1 for a flow-chart of post-hospital disposition).
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