Beyond the Doctor’s Office & ER Visit: Three Steps to Accessing Senior Care

In my previous blog titled Accessing Medical Care: Overcoming the Challenge for Senior Citizens, I provided an example about my aunt and her challenges in accessing the right type of care. As a follow-up to those challenges regarding accessing care for Senior Citizens, let’s dive deeper into the actual steps to resolve those challenges through a breakdown of care types, the level of care and differences in the process for admission to these various care sites.

Step One: Understand care settings, and their corresponding admitting criteria

• Acute Care Hospital: Acute Care Hospitals (hospitals) are a short-term medical setting designed to deliver immediate medical or surgical care and treatment. The average length of stay in an acute care hospital is typically four-six days but can vary depending upon the severity of illness or injury. Admission to a hospital requires a physician order and expectation that care will require a stay in that hospital for more than two (2) midnights. If care is expected to take less than two (2) midnights, the patient can be placed on observation status. Note that observation status vs. admission often means a change in financial coverage. Be sure to ask the doctor who can help the patient or caregivers review the insurance coverage if there are questions. The criteria for admission is dependent on various factors from the illness or injury, but essentially a physician must believe that the illness or injury is severe enough, and the services needed are intense enough, that the care can only be given safely and effectively in the hospital setting. A patient can be admitted to a hospital from their home, from a physician’s office, from an Emergency Department or from other care sites known as post-acute settings explained below (i.e., Long-Term Care Hospital, Inpatient Rehabilitation Hospital, Skilled Nursing Centers, and Nursing Homes).

Post-Acute Care: Patients may need additional assistance beyond the acute care hospital. The following sites are referred to as Post-Acute care sites. A number of these sites have evolved which has resulted in some confusion between the differences of these sites and often incorrect interchangeability of the names:

• Long Term Acute Care Hospital (LTACH): Long-Term Acute Care Hospitals are also licensed as acute care hospitals but focus on those patients that are critically ill with complex conditions with the key difference in that these patients typically require a length of stay longer than 25 days. Patients are often referred to an LTACH directly from an acute care hospital intensive care unit (ICU). LTACHs specialize in caring for patients who are ventilator dependent, have multi-organ or multi-system failure, post-surgical organ transplant complications, complex wounds, or traumatic brain injury. An LTACH has specialized critical care nurses
  

• Inpatient Rehabilitation Hospital: The Inpatient Rehabilitation Hospital is commonly referred to as an Inpatient Rehab Facility, or IRF. These facilities are the third type of hospitals licensed as acute care hospitals, with the key difference in the type of intensive rehab requirement as part of the admission screening process. IRFs focus on patients that require close medical supervision along with a multi-disciplinary intensive rehabilitation program. The patients participate in rehab therapies three hours each day for at least five days per week. Therapy must include a minimum of two types of therapies, one of which must be either physical therapy or occupational therapy. Similar to other acute care hospitals, daily physician visits are required in an IRF. The average length of stay in an inpatient rehabilitation facility is approximately 10-12 days but varies depending upon the severity of the illness/injury. The therapy team consists of specialized rehabilitation physicians and nurses, physical therapists, occupational therapists, speech-language pathologists, respiratory therapists, dietitians, and other clinicians. Patients are often referred to an IRF from a number of settings often from a hospital or sub-acute and SNF facility following a: stroke, brain injury, spinal cord injury, decline in neurological function, trauma, orthopedic surgery, or illness that resulted in a significant functional decline. Inpatient Rehabilitation Facilities offer intensive rehabilitation services aimed at maximizing function on every level to return the patient to the highest level of independent living.
  

• Sub-Acute Rehabilitation: Sub-acute rehab units have often been talked about interchangeably with Skilled Nursing Facilities (SNFs). For the purpose of clarification, sub-acute rehab units are licensed as long-term care facilities with physician oversight only required once every 30 days. While rehab therapy may be provided in a sub-acute rehab unit, it is typically only provided one-two hours a day and the average length of stay is longer, typically at 16-18 days. Approval for admission to a Sub-Acute Rehab facility requires a minimum 3-day Acute Care hospital stay occurring at least 30 days within admission to the sub-acute facility. Sub-Acute Rehab services are another option often prescribed when a patient does not qualify for the intense rehab at an IRF or skilled nursing services at a SNF.

• Skilled Nursing Facility (SNF) A Skilled Nursing Facility is another sub-acute care option for people that do not need an acute care hospital setting but still require skilled nursing care as they cannot be cared for at home. SNFs are licensed as long-term care facilities with an average of 16-18 days. The nursing care is provided typically by nurses with other caregivers assisting with meal preparation, daily living activities such as getting dressed, eating, bathing, etc. SNFs are typically units within Nursing Homes but you may find a larger combination facility that offers several sub-acute levels of care with various types of rehabilitation services.
  

• Nursing Homes: People often assume that a Nursing Home is the same as a SNF but as I noted above the combination of services may exist in one facility. However, the level of care and length of the stay changes as a patient moves from one level of care to the next and there are different requirements for admission to each even if these services exist in one facility. For the Nursing Home level of care, this care is provided mostly by nurse aides supervised by a nurse for a portion of the day. Nurses aren’t typically onsite 24/7. Patients in Nursing Homes stay much longer than any other post-acute site typically and are designed for patients who are not able to live independently. IMPORTANT NOTE: Insurance coverage for each type of Post-Acute care site can be different. For instance, Medicare only allows payment for medical care and not general assistance. Therefore, Nursing Homes would require payment by the patient, or another source of insurance besides Medicare to cover the non-medical assistance. Consulting financial counselors, case managers or social workers to help navigate and understand the types of insurance coverage for each level of care can be great sources of assistance.
  

• Outpatient Rehabilitation & Care The above descriptions focus on inpatient care. However, outpatient care can also be provided at various rehab centers where patients come to a facility for their therapy in accordance with a specified rehab schedule and then return to their home. Home Health agencies may also be an option for patients to receive care or therapy in their own home. Outpatient options require an understanding of insurance coverage differences as well.

Step Two: Know Your Rights & Advocate

It is important to be bold and advocate for the setting you believe is most appropriate for the patient. And thinking about my aunt’s case that I mentioned in the prior insight, advocacy by her family was necessary.

IMPORTANT NOTE: There is a discharge planning process that all hospitals must comply with and this process includes the Patient Choice Rule, which requires performance and quality information be shared with the patient and/or caregivers about options for the post-acute care sites. Additionally, a request to each post-acute site facility, i.e. LTACH, IRF, Sub acute, etc. can be made by the patient or caregiver for a screening of the patient (without additional costs to the patient) to provide guidance to the best type of facility. The outcome of the screening can then be provided to the physician for any necessary physician’s orders to proceed with admission.

Step Three: Choosing the highest quality location:

Once the appropriate type of post-acute setting has been determined, it is time to select the highest quality facility in the desired location for the patient. For example, when an IRF is decided as the best level of care needed for the patient, reviewing the quality indicators between the IRFs in that desired location can be very helpful. Quality information can typically be found on the individual IRF websites, from the patient’s case manager and also at https://www.medicare.gov/inpatientrehabilitationfacilitycompare/

These three steps can improve the patient’s outcomes by decreasing delays to care and ensuring the right type of care is selected and provided.