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Patients Discharged to Post-Acute Care
35% of Medicare beneficiaries discharged from short-term acute hospitals receive post-acute care Higher Intensity of Service Lower SHORT-TERM ACUTE CARE HOSPITALS LONG-TERM ACUTE CARE HOSPITALS SKILLED NURSING FACILITIES HOME HEALTH CARE INPATIENT REHAB OUTPATIENT REHAB Patients’ first site of discharge after acute care hospital stay 2% 10% 41% 9% 37% Patients’ use of site during a 90 day episode 2% 11% 52% 21% 61% Medicare Patients’ Use of Post-Acute Services Throughout an “Episode of Care” * * Source: RTI, 2009: Examining Post Acute Care Relationships in an Integrated Hospital System
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Multiple Post-Acute Care Settings
PHYSICIANS (PRIMARY CARE AND ATTENDINGS) SHORT-TERM ACUTE CARE HOSPITALS 1ST POST-ACUTE SETTING 2ND POST-ACUTE SETTING 3RD POST-ACUTE SETTING Admit Care Discharge Admit Care Discharge Admit Care Discharge MANAGED CARE PAYORS with CASE MANAGEMENT
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Standard Care Summary (HL7 CCD) Enhances Care Coordination
Demographics Problem List Allergies Medications Procedures Results Care Summary HL7 CCD Demographics Problem List Allergies Medications Procedures Results Care Summary HL7 CCD PHYSICIANS (PRIMARY CARE AND ATTENDINGS) SHORT-TERM ACUTE CARE HOSPITALS 1ST POST-ACUTE SETTING 2ND POST-ACUTE SETTING 3RD POST-ACUTE SETTING Demographics Problem List Allergies Medications Procedures Results Care Summary HL7 CCD Demographics Problem List Allergies Medications Procedures Results Care Summary HL7 CCD Admit Care Discharge Admit Care Discharge Admit Care Discharge MANAGED CARE PAYORS with CASE MANAGEMENT
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What is needed to fully coordinate care?
PHYSICIANS (PRIMARY CARE AND ATTENDINGS) SHORT-TERM ACUTE CARE HOSPITALS 1ST POST-ACUTE SETTING 2ND POST-ACUTE SETTING 3RD POST-ACUTE SETTING ? ? Admit Care Discharge Admit Care Discharge Admit Care Discharge MANAGED CARE PAYORS with CASE MANAGEMENT
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