1. The Transformers: Institutional Options for Acute and Post-Acute Care – Role of the Physiatrist
Bruce M. Gans, MD

2. What makes a smart health care system from the perspective of the patient
Patient-centered, not facility- or provider-centered
Caring about the patient as an individual in the context of family and community
Caring about function and quality of life as well as health status
Protecting the patient’s economic and human resources
Safe, high quality care
Long-view as well as short-term perspective

3. Care coordination – Why is it so hard?
Dollars do not drive us there (at least not very far)
Few acute care professionals really know the long-term consequences of disabling conditions
Few acute care professionals really understand the different post-acute settings

4. Care coordination – Why is it so hard? (continued)
Decision tools and decision makers tend to be biased
Insurance company tools (Milliman, InterQual)
Clinicians who are highly invested and motivated by providers they work for or with
Patients and families are largely not well informed and able to execute good choices based on adequate information about the post-acute settings
Pressure of time forces “haste makes waste” choices

5. Simple minded solutions
Plan Ahead
Anticipate future needs (both short- and long-term)
Put people who know and understand the long-term into the acute (and hyper-acute) care settings to do a and b above
Rely on best available evidence and expert clinical opinion
Learn from the long-term consequences of near-term decisions and hold near-term decision makers accountable for the long-term outcomes.

6. Examples of practice and institutional models in operation
Health systems that organize the continuum of care as a whole
Rehabilitation Joint Ventures that span the whole continuum of care
Embedding physiatrists into the acute care enterprise
Teaming physiatrists with clinical liaisons

7. A possible future model – the Continuing Care Hospital

8. Technical Story New provider type
Operational attributes of LTCH, IRH/U (IRF) and SNF
Single medical decision maker
Single payment (prospective) based on patient characteristics
Single outcome measurement system
Internal freedom to flex resources to patient need
Elimination of regulatory requirements that bar any of the above

9. Economic Story Need to create a new payment system
Hard to quantify the economic benefits
Fear of creating a new provider type without restraints

10. Political Story Included (twice) into ACA
Opposed (or at least not supported) by CMS
A dolphin caught in the ACA Tuna Net?

11. Where it might go from here

12. Impact of the CCH on physiatry practice
Clinical role and care
Teaching
Research

13. Questions?