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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #29, #30, #31, #42, #50, #71


Learning Objectives

  • Improve understanding of how the affordable care act and the creation of accountable care organizations (ACOs) is impacting postacute care.

  • Understand the types of postacute settings and what differentiates them.

  • Define the role of physicians and other medical care providers (nurse practitioners [NPs], physician assistants) in subacute care.

  • Identify the key issues that need to be addressed in order to have high-quality care transitions from the hospital to skilled nursing facility (SNF) setting.

Key Clinical Points

  1. Patients in the subacute care setting have diverse needs ranging from short-term orthopedic rehabilitation to complex medical management to end-of-life care.

  2. Clinicians in the subacute setting must be skilled in using systems that enable them to collaborate effectively with hospital-based and the primary care physician.

  3. Clinicians in the subacute setting must be highly skilled in managing geriatric syndromes as well as having expertise in pain and symptom management.

  4. Advance care planning must be integrated into the overall care of patients in the subacute setting.


The Affordable Care Act has provided a tremendous incentive to stimulate innovation in the postacute care setting. Newspapers, television news shows, blogs, and podcasts discuss the impact of health care reform on how health care is delivered. The mantra of controlling cost and improving quality of care is heard incessantly and has started a wave of initiatives that are impacting all areas of health care including postacute care. The Institute of Health Care Improvement has developed a vision to meet three goals that in the past were targeted separately, but now are being addressed under a single unifying vision, the Triple Aim. The Triple Aim is attempting to improve care and costs by addressing simultaneously three essential components of health care:

  • Improving the patient experience of care (including quality and satisfaction)

  • Improving the health of populations

  • Reducing the per capita cost of health care

The philosophy delineated by the Triple Aim is impacting many local health care markets in a dramatic fashion by aligning hospital systems, multidisciplinary group practices, skilled nursing facilities, and home care agencies to better coordinate care and to provide that care in the most appropriate setting from both a quality and a cost perspective.

We are now seeing partnerships and collaborations evolving that are both formal and informal, among primary care practices, insurers, and hospitals with the postacute facilities they use. The care continuum is being coordinated in many regions in what is sometimes called a vertically integrated system. Postacute provider networks that include hospitals, nursing facilities, and home health agencies are being created. Care managers that can work for insurers, medical practices, or hospitals are being assigned to facilitate and monitor the patient’s journey through the care continuum.


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