Clinical Experience
The Successful Development of a Subacute Care Service Associated With a Large Academic Health System

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Abstract

Ensuring the safe transition of patients from hospitals to skilled nursing facilities and from skilled nursing facilities back to the hospital or the community can present significant challenges. The University of Michigan Health System was able to overcome many of these challenges through the implementation of a health system associated Subacute Care Service that consists of the University of Michigan Health System geriatricians and nurse practitioners working in privately operated skilled nursing facilities in our primary market area. We describe the planning process surrounding the development of the Subacute Care Service and report on efforts to date.

Section snippets

Overview of Subacute Care in Skilled Nursing Facilities

The term “subacute care” refers to postdischarge skilled care provided in an SNF. Generally speaking, there are 2 distinct patient populations cared for in SNFs. The first is composed of long-term patients for whom the SNF serves as a primary residence. These long-term patients usually receive medical care by an attending physician or the facility's medical director during monthly visits. Payment for long term care services comes from several sources, including Medicaid, the Department of

Developing a New Subacute Care Service and the Emergence of the “SNFist”

The UMHS is a 914-bed tertiary care center located in Ann Arbor, Michigan, with an annual patient volume of approximately 45,000 inpatient admissions and 1.8 million outpatient visits. Launched in 2006, the SACS was envisioned as a way to enhance the overall quality of care for patients discharged to SNFs while simultaneously decreasing inpatient length of stay and readmissions. Currently, the program is staffed by 4 full-time physicians along with 5 full-time clinical nurse practitioners.

Financial Model for a Subacute Care Service

Critical to the successful creation of the SACS was an integrated financial model that closely aligned both health system and physician incentives. This type of model, involving both hospital and physician practice salary structures, has provided a successful paradigm for hospitalist programs throughout the United States. After assessing potential return on investment for days saved and reduced readmissions, the UMHS leadership determined that the investment needed to create the SACS was

Identifying SNF Partners for the Subacute Care Program

In preparation for hospital discharge, patients and their families often choose an SNF based on proximity to their home and the physical appearance of the facility. When a health system seeks to partner with a privately owned SNF, certain criteria can aid the selection process (Table 1). For instance, facilities that have made the necessary investments in staffing and physical plant are more desirable. Facilities should have an established record of caring for high-acuity, posthospital

The Subacute Care Service Medical Director

The SACS medical director (D.K.J.) serves as a visible clinical and administrative leader for the entire service. The director plays a critical role in assuring hospital-based physicians that they can discharge their patients to a SACS-associated SNF with confidence. At our institution, this is accomplished in part by highlighting the frequency of physician visits (clinicians are now in the SNFs 7 days a week) along with use of a common electronic medical record. This type of outreach has

The Role of the Electronic Medical Record

When a patient is discharged from the hospital, both the patient and the SNF are provided with a written discharge summary. Although this summary contains diagnoses and medications, it does not contain a comprehensive listing of tests, procedures, and consultations that occurred during the hospital stay. This lack of fundamental information can lead to redundant laboratory testing, medication errors, and even readmissions.

The observation that patients in subacute care have among the highest

Pharmacy and Laboratory Services

Most SNFs contract with private pharmacies to supply medications. These pharmacies have developed their businesses by providing medications for a static, long term care patient population with low turnover, infrequent medication changes, and once-daily shipments for new medications. As SNFs have moved toward admitting more medically complex posthospital patients, their pharmacy contractors have struggled to provide medications with the timeliness and frequency required. In addition to problems

Decreasing Readmissions: Preventing “Bounce Backs” Among Complex Patients

Since its inception, our SACS has successfully managed a population of highly complex medical and surgical patients. Before creation of the service, many of these patients experienced lengthy hospital stays, often several weeks to months. Accordingly, shorter hospital lengths of stay for high-acuity patients can increase the risk of readmissions to the hospital or “bounce backs.” Although there are myriad reasons why the subacute population encounters a high rate of readmission, we believe that

Post Subacute Discharge Planning

During a typical SNF stay, many adjustments are made in a patient's care plan, including the dosages and even types of medications.16 That said, most patients who are discharged from an SNF receive a handwritten medication list along with new prescriptions as the only form of discharge communication. As a result, primary care providers and homecare nursing agencies are often completely uninformed about the details of the SNF stay.16, 17 To remedy this lack of information transfer, each

Palliative Care in the Subacute Setting

Candid discussions about goals of care are an increasingly common occurrence in the subacute setting.18 The patient's hospital stay is often relatively brief, with the inpatient team focused on making a diagnosis and beginning treatment as quickly and efficiently as possible. As a result, the patient who has a poor long-term prognosis does not always receive sufficient face-to-face physician time in the hospital to allow full understanding and acceptance of this limited prognosis and, at times,

Results to Date

Periodic review of SACS outcome data has been an important aspect of the evaluation process, which is ongoing. Positive results have helped support continued, fiscally responsible growth of the SACS.

Table 2 illustrates key indicators and metrics that were established jointly by UMHS and the SACS leadership before launching the program. Since then, the portion of UMHS patients receiving subacute care at one of the SACS-associated SNFs has increased from 42% to 45%. Average length of stay before

Health Care Reform and the Future of Subacute Care

The passage of the Affordable Care Act and bundled payment models will undoubtedly affect the nature of the business relationship between hospitals and SNFs. Shared payment and savings models for reimbursement will create strong incentives for health systems and SNFs to provide a more efficient and “lean” transition of care from the acute to postacute setting. In addition, there will be incentives to improve the quality of care in the SNF so as to avoid unplanned readmissions. Meeting these

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The author have declared no conflicts of interest.

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