Rehabilitation facilities. Aren’t those just nursing homes? Do you mean to tell me that if I don’t go home from the hospital, that I’ll have to go to a nursing home? I’m barely fifty. I don’t need that.
Such are the concerns voiced over and over in recent days. That hip replacement that you underwent may only allow you to benefit from two days in the hospital. But if you’re lucky, you may be able to get your insurer to pay for another week in a rehabilitation facility. Or if you had a severe heart attack, perhaps requiring open heart surgery, the same may be possible for you. The more complicated your hospital stay was, the more likely you might qualify for a short rehabilitation stay.
But what happened to the true rehabilitation hospitals? Unfortunately they have been a victim of cost cutting. They are now limited to patients who might have required prolonged ICU stays, on artificial ventilation, who truly have complex, ongoing medical issues which, in the past, would have required ongoing hospital care. For less complex patients, nursing homes have had to step up.
But aren’t nursing homes limited to the elderly, who have no one to care for them? Historically yes. But nearly twenty years ago, when the need for further in-patient care was required beyond a patient’s approved hospital stay, nursing homes began to step up their game, developing robust therapy departments for that purpose. And space was set aside in their buildings for subacute patients; that is patients that were expected to remain in the facility for limited periods of time. And in many cases, the therapy departments began to emerge as more robust even than many in-hospital departments, simply because patients weren’t staying in the hospitals long enough to benefit from a robust therapy department.
But as patient discharges began occurring earlier and earlier, the acuity of their medical issues continued to escalate as well. Soon facilities, which had ramped up their therapy departments, were also being confronted with medically complex patients whose issues had barely had a chance to stabilize. And the medical care that they required, care which had been provided by physicians in the hospital, had now been handed off to nursing staff, many of whom weren’t even registered nurses.
And the facilities were charged with keeping these complex patients from returning to the hospital within thirty days of their discharge from the hospital. And in many cases charged with getting them healthy enough to return home within 1-2 weeks. Complicating matters was the fact that physicians, who nominally provided care to those patients in the hospital, rarely visited these facilities.
Some nursing home chains began to explore hiring their own physicians, to provide a regular presence in the nursing home, allowing hospital level of care to take place within their facilities. However, the cost of providing that care is becoming prohibitive. While hospitals, on average, may receive in excess of $1500 per day for care, the average nursing home is lucky to receive $500 for that same care.
To make matters worse, the value based purchasing guidelines which were implemented for hospitals around 2010, are going into effect for nursing homes as well. In other words, they can also be subject to penalty repayments for prolonged stays and for 30 day bounce backs to hospitals. And with operating margins that are much more limited than hospitals, their very existence is being threatened.
So what can be done as the can keeps getting kicked down the road. If nursing homes will no longer be able to provide care of the necessary length and intensity, where are patients to go?
Certainly keeping many patients in a supervised setting is to be preferred. Maybe step increases in daily rates based on the acuity of care provided may help subacute units to continue to operate. But in the meantime, what are patients to do?
Here’s where home health agencies need to step up their game. But how will this impact the life of the average patient? And do cost controls impact on this important safety valve? For the answers, check in with us next time.