A recently aired radio advertisement states, “Nursing Homes: not just for the end of life anymore.” While the number of elderly persons residing permanently in nursing homes has remained stable over the past several years, increasing numbers are admitted to nursing homes for short-term stays, usually for rehabilitation or continuing medical management after an acute hospitalization. Indeed, the past 15 years has seen the establishment of a whole new area of medicine, termed “subacute care,” “postacute care,” or “transitional care,” along with units that specialize in this care. While subacute care can be delivered in both free-standing skilled nursing facilities (SNFs) and in hospital-based transitional care units, the former have come to dominate the industry over the past 5 years. Subacute care is an important component of the continuum of care for elderly persons, and care in this setting is frequently provided by geriatricians and geriatric nurse practitioners. In fact, subacute care is an important clinical niche of geriatric medicine.
This chapter discusses the fundamentals of subacute care from the perspective of clinicians delivering care in this setting. After defining subacute care and its providers, the chapter follows the timeline of subacute care, beginning at the hospital, to subacute admission, assessment, care planning, medical management, and discharge planning. The chapter also briefly touches upon the financial and medicolegal aspects of providing care in this setting and highlights aspects of medical management and decision making that may be unique in the subacute setting.
There is some debate about the exact definition of subacute care. In fact, there is a great deal of variation in the settings, patients, and providers encompassed within subacute care. In this chapter, subacute care is defined as the management of discrete episodes of illness requiring medical management and/or functional rehabilitation within the SNF. The intensity of the medical management is generally less than that provided on a general medical/surgical unit in an acute care hospital, but greater than what can be provided in the traditional nursing home setting, or at home. The level of functional rehabilitation provided is less intense than in a specialized rehabilitation hospital, but greater than that provided at home. Usually, but not always, subacute care provides a continuation of a treatment plan initiated in the hospital. The frequency of medical encounters and the costs of care are also intermediate between the hospital and long-term care settings.
A major distinction between acute care and subacute care is a focus on function. This makes it an ideal setting for geriatricians. Acute care in hospitals is focused on diagnosis and targeted aggressive treatment of acute medical problems. Unfortunately, as a result of hospitalization, many elderly persons suffer nosocomial complications and functional decline that persist well after the acute problem is corrected. Innovative models have been developed to reduce the risk of delirium and functional decline in acute care hospitals; nonetheless, these problems remain rampant, particularly in frail individuals with underlying dementia or chronic medical ...