This is the Healthcare Delivery Providers, part of the Healthcare Marketplace Specialization. This is Module 3.1.3, Overview of Post Acute Care. And we'll look at Trajectories and Configurations. So in this lecture, we will look at the various trajectories in post acute care. And what I mean by that is the patient could go from the hospital to home healthcare. Patient could go from the hospital to a nursing home. Patient could go from the hospital to the nursing home to home care then to a primary care clinic and living at home. So those are what I call trajectories, and many different patients based upon their complications and their conditions like Harlan Reeves, flow differently through different value chains of healthcare delivery, so that's what I mean and that's what we will learn about in this particular lecture. Okay, so back to our patient, Harlan, and think about the time or the hours when he is in the hospital, he's getting better and does not need hospital level services anymore, so he's ready for what we say, discharge, and is about to be sent out into the community. Where does the patient go, how is that determined? And so these are the four main categories of what influences the decision on where the patient goes. First is the patient's choice, of course, so does he have family support? Is he willing to go to the place the physician wants to send him? What are the treatment preferences? The next big thing is the clinical need, so is the heart failure much better? Does the patient need to go directly to home, or do they need to go to a nursing home for a few days first? What are their other medical conditions? What's the prognosis? And then also there are different coverage rules on what the payers will pay for, or not. The third main factor is the post acute care facility specialization or competency. Proximity is huge. Families want to visit their loved ones, so they want the mom or their dad or the loved one to be right next to their homes. So again, proximity matters, sometimes at the cost of quality. The capacity does, is there bed open in the nursing home, or can the home health care take another patient? And then what's the relationship between the acute care hospital and post acute care site? Is it contracted? Is it in the same network, is it part of the same ACO, all those things matter. And finally, the physician also counts. What is the physician's opinion of the post acute care facility? Again, marketing and branding matters. Also, physicians, remember the last few patients. Have they done well at a particular nursing home, or have they not done well? And that really determines the practice patterns. So again, these four things really impact where does the patient go. So as we've discussed in the trajectories, the patient could go from the hospital to the LTACH, then to the IRF, then to the SNF, sometimes could get worse, back to the hospital, and because the patient is sicker now, to the LTACH again. Got better, maybe could go to the SNF, go directly now to home health care. Sometimes, from the hospital, the patient is not as sick, so could go directly to home health care. Sometimes the patient are even, let's say they could directly home to get outpatient rehab. So there are percentages, about 40% of patients from a hospital going to some kind of a post acute care facility, and the rates of readmission, so all of these tracks back are called the readmissions within 30 days are pretty high. The higher the acuity,so LTACHs have a much higher rate of readmission than IRFs. So about 20% or so of the heart failure patients, for example, through these facilities typically will go back and bounce back within 30 days to the hospital. Here is a schematic that shows that. So acute care hospital, 30% of the patients go to a skilled nursing facility, then go to a second post acute care site, so maybe 8% will go home with home health care. Then 5% of the SNF patients go back to the hospital maybe, and then of those patients 3% go back to a SNF. So again, the bouncing around is quite common. Same deal can happen with home health care. 32% of the patients go home with home health care, 6% of those bounce back to acute care hospital. Again, 2% of those could go back to home health care, and so on and so forth. So again, a pretty complicated back and forth trajectory which is not very smooth. Let's do a quiz. So, this is a diagram that I've used for a few years to show the current flow of post acute care in Community Services. So, notice the arrows. From home, a lot of patients go to acute care. And then from acute care, they divide up according to various percentages into these various post acute care facilities. Now here's what a re-engineered process might look like. So what about instead of going to acute care first a lot of the patients that need some services could be matched up with some kind of a post acute care facility. Before acute care. So isn't this amazing, that post acute facilities could actually be re-engineered to be pre-acute care facilities? So Harlan Reeves starts having difficulty breathing, and directly gets plugged into home health care, gets better, and may never need to go into the acute care hospital. Same deal could happen with long term care or a nursing home or assisted living. So again if we re-engineer the process and plug the right patient to the right setting of the care at the right time, this arrow could go down. And overall, the quality would go up and the cost would go down. So again, that's something that we will be discussing quite a bit over the next, coming modules and lectures. Here's the traditional home and community based services module, or the model. So usually, traditionally, a lot of skilled nursing beds were there, so nursing homes were big. Assisted living facilities were moderately sized, and home health care or other home and community based services, like assisted living, or the other community based services, were at the tip of the iceberg. But again, the majority of the patients lived in nursing homes. Now what's happening is that the pyramid is getting inverted. So, more home based and community based services, more assisted care, living settings, and housing alternatives, and decrease in institutions and skilled nursing facilities. So trying to move Harlan not staying just in the nursing home for years. We're actually sending him home with enhanced services to improve quality, improved quality of life and also reduced cost. I'll briefly describe a couple of different PAC configurations that I am seeing emerge in the US. So here's a post acute care campus, still has quite a large skilled nursing facility with beds, and part of that we will discuss. A small part could be the short stay patients, a larger part could be the long stay patients that live there. Another piece on the campus might be assisted-living facility where patients can buy up services, but their usually independent units of living. On this side of the campus could be adult day care. Where patients can be dropped off during the day and picked up in the evening. Over here could be a gym, could be a pool. So again, this is the new post acute care enhanced campus with many different services on the same campus and the same patient can move from assisted living to short term rehab to long term stay, if they need, without moving from the same campus. Another way of looking at the PAC configuration might be here is a nursing home, here's another nursing home, another nursing home, here's a home health care agency, here's assisted living. A unit, and so these could vertically integrate with a hospital that's part of an ACL or a system. Another thing that could happen would be that the nursing homes, let's say these are nursing homes, could horizontally integrate, and this is vertical, vertical integration or horizontal integration to get to a post acute care heft. So again, that's economies of scale and economies of scope, again, to improve quality and overall reduce cost. So in summary there are many, many, many possible trajectories within post acute care, and again these depend upon the patient's complexity choice and many other factors. And then, post acute care configuration and alignment with the rest of the delivery system, is changing. Especially as the triple aim comes to be, and accountable care organizations flourish in the U.S.
