A recently aired radio advertisement states, “Nursing Homes: not just for the end of life anymore.” While the number of elderly persons residing permanently in nursing homes has remained stable over the past several years, increasing numbers are admitted to nursing homes for short-term stays, usually for rehabilitation or continuing medical management after an acute hospitalization. Indeed, the past 15 years has seen the establishment of a whole new area of medicine, termed “subacute care,” “postacute care,” or “transitional care,” along with units that specialize in this care. While subacute care can be delivered in both free-standing skilled nursing facilities (SNFs) and in hospital-based transitional care units, the former have come to dominate the industry over the past 5 years. Subacute care is an important component of the continuum of care for elderly persons, and care in this setting is frequently provided by geriatricians and geriatric nurse practitioners. In fact, subacute care is an important clinical niche of geriatric medicine.

This chapter discusses the fundamentals of subacute care from the perspective of clinicians delivering care in this setting. After defining subacute care and its providers, the chapter follows the timeline of subacute care, beginning at the hospital, to subacute admission, assessment, care planning, medical management, and discharge planning. The chapter also briefly touches upon the financial and medicolegal aspects of providing care in this setting and highlights aspects of medical management and decision making that may be unique in the subacute setting.

There is some debate about the exact definition of subacute care. In fact, there is a great deal of variation in the settings, patients, and providers encompassed within subacute care. In this chapter, subacute care is defined as the management of discrete episodes of illness requiring medical management and/or functional rehabilitation within the SNF. The intensity of the medical management is generally less than that provided on a general medical/surgical unit in an acute care hospital, but greater than what can be provided in the traditional nursing home setting, or at home. The level of functional rehabilitation provided is less intense than in a specialized rehabilitation hospital, but greater than that provided at home. Usually, but not always, subacute care provides a continuation of a treatment plan initiated in the hospital. The frequency of medical encounters and the costs of care are also intermediate between the hospital and long-term care settings.

A major distinction between acute care and subacute care is a focus on function. This makes it an ideal setting for geriatricians. Acute care in hospitals is focused on diagnosis and targeted aggressive treatment of acute medical problems. Unfortunately, as a result of hospitalization, many elderly persons suffer nosocomial complications and functional decline that persist well after the acute problem is corrected. Innovative models have been developed to reduce the risk of delirium and functional decline in acute care hospitals; nonetheless, these problems remain rampant, particularly in frail individuals with underlying dementia or chronic medical illnesses. Add to this the continuing pressure to shorten length of stay, and many acutely hospitalized elderly persons are unable to return to their residences at discharge. Subacute care has filled the need for a place where these patients can receive ongoing medical and nursing care, in addition to skilled rehabilitation and discharge planning for eventual return to the community. Length of stay in subacute care varies widely, from less than 1 week up to 100 days (the Medicare limit), but the average is generally 1 to 3 weeks.

Subacute care plays a particularly important role in the managed care system for several reasons. First, the cost pressures engendered under managed care require treating patients in the least costly environment that meets their needs. Second, many managed care plans have per diem rates with acute care hospitals, leading to even more intense pressure for discharge than the traditional Medicare diagnosis-related group (DRG) system. Third, managed care plans are exempt from the “3-day” hospital rule (in traditional Medicare, patients must be hospitalized for at least 3 nights to qualify for a skilled nursing benefit), so that these patients can access their SNF benefit with a shorter hospital stay, or even be directly admitted from the community (often via the doctor’s office or emergency department). For all of these reasons, managed care plans tend to admit sicker patients to SNFs for shorter lengths of stay, and managed care providers have been the leaders in developing expertise in subacute care. Foremost has been the establishment of teams of physicians and nurse practitioners who spend most or all of their professional lives delivering subacute care. These teams have developed protocols for facilitating hospital transfers, assessing patients, delivering sophisticated medical care, addressing acute medical problems, minimizing rehospitalizations, providing case management, and proactive discharge planning. Each of these is discussed in greater detail later in this chapter.

Compared to the usual nursing home population, subacute patients tend to be younger (average age in seventies rather than late eighties), more acutely ill, but less likely to have dementia or major chronic functional limitations. Most patients admitted for subacute care come directly from hospitals and are expected to return to their homes after a specific, planned treatment course. However, a small but significant fraction of subacute patients (10% to 33%) never achieve discharge goals and “convert” to long-stay nursing home patients. Another significant fraction of patients become medically unstable in the subacute setting and need to be rehospitalized (up to 25%). A third group of patients present with advanced illness and receive end-of-life care and die in the subacute setting. These figures depend on the acuity of illness and underlying frailty of the population, as well as on the quality of care provided at the facilities. Except for the dying patients, maximizing return to the community, and minimizing rehospitalizations and long-term care placements are worthy goals of subacute care. Typical subacute diagnoses include hip fracture, other fractures (upper extremity or vertebral), stroke, cardiac and pulmonary conditions (including pneumonia), pressure and vascular ulcers, postoperative care, and deconditioning. Subacute patients may need intensive medical management, functional rehabilitation, or a combination of both. As noted above, some also receive formal hospice or hospice-like services in the subacute setting.

Delivering effective care to the subacute population requires a much greater physician presence than traditional long-term care. Just as the term hospitalist denotes physicians working primarily in the hospital, SNFist and subacutist are terms occasionally used to describe clinicians practicing primarily in the subacute environment. Practicing as a long-term care and subacute care clinician requires a special set of skills. Physicians working in SNFs and subacute units are usually geriatricians or other clinicians with strong geriatric skills such as internists, osteopathic physicians, and family practitioners.

A number of clinical, administrative, and interpersonal skills are important for a physician to achieve success in the area of subacute care. To properly manage this challenging patient population, the nursing facility clinician must have clinical expertise in managing conditions that are a blend of office, hospital, and geriatric practice (Table 20-1).

Leadership skills are highly desirable in the physicians practicing in this setting. The physician is the leader of the facility interdisciplinary team whose members include rehabilitation specialists, nurses, social service, and case management. The subacute setting is an environment that benefits greatly from a physician leading the geriatric care team.

Administrative skills are also important for the subacute care practitioner. Nursing facilities have a relatively simple administrative structure. The administrator and director of nursing are the primary salaried personnel that run the facility. There is a facility medical director as well. Attending physicians have the opportunity to work closely with these three individuals in a facility. Attending physicians, even if they are not the medical director, can make significant contributions to the quality of care of subacute patients (Table 20-2).

Interpersonal skills are the third key area for subacute care practitioners. The ability to form trusting collaborative relationships with patients and families quickly is critical to effective care in nursing facilities. Patients currently entering nursing facilities are often critically ill, are more dependent than previously, fear loss of independence, have caregivers under great stress, and often have financial and housing pressures. They may also be suspicious of nursing facilities and may not understand all of the medical issues. Table 20-3 summarizes the interpersonal skills needed in a subacute care provider in order to handle these issues.

Daily rounding by a clinician with round-the-clock phone availability is essential to providing effective subacute care. To provide this enhanced clinical coverage, physicians may collaborate with advanced practice clinicians (APCs) such as nurse practitioners and physician’s assistants. APCs play a major role in providing care in many subacute units. States and facilities vary regarding the scope of practice for APCs. In some locales, nurse practitioners practice as independent clinicians, while in others, direct physician supervision is required. Many facilities require written guidelines that describe the scope of practice of the APC as well as the manner by which physician supervision will be provided.

The physician working in a subacute care setting may find tremendous benefit from working with an APC. Many APCs have specialized areas of expertise that complement the skills and knowledge of the physician. Table 20-4 lists the roles and duties an APC can assume in a subacute unit.

A physician practicing with an APC has the opportunity to form a team that can improve the quality of care provided and can improve job satisfaction for both providers. As in other teams, excellent communication, trust, availability, and support are essential.

The model of physician–APC collaboration in the subacute setting has many similarities to an inpatient hospital model. The APC may operate much like a first-year resident, managing day-to-day issues, identifying new issues, and requesting support from the physician when needed. By rounding together on a regular basis the MD–APC care team have the opportunity to assess patients together. Patients can be reassured seeing their care team together. There is no substitute for a bedside evaluation in assessing issues such as pain control, cognitive status, anxiety, and medical stability. APCs are able to participate in night and weekend on-call duties. It is essential that if an APC is taking “first call” that there always be a physician available for consultative support.

It is preferable to have a model of on-call coverage that uses clinicians who not only know the patient but also the capabilities of the facility. When it is not possible to have a clinician who is a direct caregiver providing on-call coverage, effective signouts are important. Key clinical information can be transmitted by direct verbal communication or, with HIPAA appropriate safeguards to ensure patients confidentiality, by written summaries that can be faxed or e-mailed to the covering clinician.

Subacute care units are licensed and regulated under the same regulations as nursing homes. In 1987, a set of regulations regarding patient care in nursing facilities was enacted in the Omnibus Budget Reconciliation Act (OBRA). These regulations laid out a number of principles that were used to standardize care in nursing facilities. In 1995, the nursing home certification and enforcement regulations took effect. Unless nursing facilities were found to comply with the standards laid out in OBRA, they would not be allowed to participate in the Medicare and Medicaid programs. Table 20-5 summarizes key aspects of the OBRA regulations. These principles provide a framework for providing appropriate clinical care. Physicians must work collaboratively with nursing facility staff to maintain compliance with OBRA regulations. It is particularly challenging managing a high turnover, higher acuity population under these regulations. Excellent assessment skills, complete and accurate documentation, and a well-functioning interdisciplinary team are necessary to meet regulatory requirements, and are also the cornerstone of good subacute care.

Quality in subacute care goes beyond traditional medical process and outcome measures emphasized in hospitals. Perhaps most important is the quality and availability of the nursing staff. Because of the stress of managing high-acuity patients in the nursing home setting, many subacute facilities are chronically understaffed, or experience high staff turnover, especially of licensed nurses and nursing aides. Significant use of “agency” personnel, with little knowledge of the facility or its patients, can have a major negative impact on quality. Additional issues that are of great importance in the subacute setting include the quality of the rehabilitation services for patients with medical conditions that are likely to improve, and palliative care services for patients whose clinical status is likely to deteriorate. Subacute facilities are also judged on their hotel services in addition to their medical services. Good food, pleasant ambience, television, and clean rooms are all part of the reasonable expectations of patients and their families. Subjective measures, such as patient and family satisfaction, and the facility’s reputation in the community, can be good overall measures of quality.

The vast majority of subacute patients are transferred from acute care hospitals. The providers at the hospitals have a critical role in ensuring the success of the subacute stay. Often, hospital providers operate with little knowledge of the facilities to which they are sending their patients. A brief communication between the hospital and subacute clinicians can help to answer questions about appropriateness, timing of transfer, specific treatments, and overall goals of care. Unfortunately, this type of communication is more the exception than the rule. In general, if the acute care hospital providers have any questions or concerns about transfer of a patient, it is best to ask before acting.

The first question to be asked is who should be sent to subacute care, and who should not? Subacute facilities vary widely in terms of their capabilities, so there is no general answer. Hospital physicians often make the naïve assumption that the nurses “screening” patients for facilities have intimate knowledge of them and can make appropriate referrals. Often, these screeners work for large corporations that may have several facilities in a large urban area. The screeners focus more on “filling beds,” and leave it up to the clinicians to determine appropriateness. It is also important to note that once a patient is accepted by a facility, the actual transfer may not take place for 1 to 2 days. During that time period, the patient may change clinically so it is important to reassess for clinical appropriateness at the time of transfer.

A few rules of the thumb hold: in general, a patient requiring the intensive care unit (ICU) is not appropriate for subacute care. The rare exception is a stable ventilated patient who is being transferred from an ICU to a specialized pulmonary subacute facility. In addition to ICU care, few subacute facilities have sophisticated cardiac monitoring, and so patients with active cardiac issues such as unstable angina, poorly controlled congestive heart failure, or arrhythmias requiring continuous monitoring are rarely good candidates for subacute care.

Nursing care in subacute facilities is much less intensive than in acute care hospitals. While hospitals rarely have more than 7 patients per nurse, subacute units may have from 12 to 20 or more patients per nurse—in an 8-h shift, this averages to as little as 20 minutes per patient. Therefore, patients with hemodynamic instability, on multiple intravenous medications, or other situations requiring close nursing monitoring, maybe poor candidates for subacute care. It is therefore critical that an assessment is made to be sure that the needs of the patient can be met with the staffing available. In general, patients with a relatively straightforward treatment plan for acute illness that has shown evidence of improvement, combined with established treatment of chronic illnesses and functional rehabilitation needs, are the most ideal for this setting.

On the opposite end of the spectrum is a patient who will likely be able to go home within a few days. For these patients, an additional facility transfer is probably not worthwhile or necessary, and runs the risk of introducing further discontinuity. In general, subacute stays substantially shorter than 1 week should be avoided in favor of direct discharge to home.

Another issue is selecting the best facility for the patient. This is a complex issue that involves both clinical and psychosocial factors. Screeners and hospital case managers often need to be focused on getting a bed quickly rather than finding the best facility for the patient. In addition, bed availability can at times be an issue. Facilities vary widely in their capabilities, and some have specialized programs in specific areas, such as orthopedics and stroke care. In general, knowledge of a proven track record of success handling a particular kind of patient is the best proof of the wisdom of transfer. In addition to these clinical issues, patients and family members may prefer a facility close to home, which can facilitate family visits and the like. These preferences should be honored if all else is equal. However, it should be explained to patients and family members that because only a short-term stay is anticipated, established medical care linkages and proven clinical excellence should outweigh geographic convenience to ensure the best possible outcome.

The optimal time for transfer can be defined as the point when the patient’s needs can be met as well or better at the subacute facility as in the hospital. In practice, this is often hard to define, and discharge is often dictated by bed availability or “critical pathways” that predetermine length of stay. Ultimately, it is the physician’s responsibility to determine whether the patient is clinically ready for transfer, and for ensuring adequate transfer of information with the patient for continued implementation of the plan of care. It is better to keep the patient for an extra day in the hospital than to risk a rapid readmission for medical instability or poorly coordinated transfer.

When the time for transfer comes, it is crucial that the appropriate information accompany the patient. Table 20-6 describes the key information required by the SNF. In addition, the physicians at the hospital should review the discharge summary and other key transfer documents to ensure that there are no discrepancies—if so, these should be remedied.

Developing better systems whereby receiving facilities and sending hospitals coordinate the transitions of care is crucial to improving patient care and optimizing outcomes. One approach can be achieved through sharing information via computer systems. Clearly, this is easiest for onsite transitional care units (which are becoming less common). However, even free-standing subacute facilities can have dial-up or hard-wired computer links with sending hospitals. Only certain members of the subacute staff (particularly the physicians, who may also be on staff at the sending hospital) receive access to key elements of the patient’s record, as well as the ability to e-mail hospital providers.

Understanding the limitations of subacute care facilities can help hospital providers better manage the transfer of care. First, consider the timing of transfer. Unfortunately, most patients arrive for admission to SNFs between 4 and 7 p.m. However, staffing at most SNFs is best on the day (7 a.m. to 3 p.m.) shift. Therefore, hospitals should attempt to transfer the patient as early as possible during the day, preferably before noon. Before sending the patient, hospital providers should ensure that all patient needs, including nutritional, are met for the next several hours. Second, consider that most SNFs do not have onsite pharmacies and that it may take several hours for ordered medications to be delivered to the patient. Therefore, all medications, particularly pain medications that the patient will need over the next 4 to 6 hours, should be administered prior to transfer. Finally, SNFs may have difficulty inserting and maintaining intravenous access. Therefore, stable access should be ensured prior to transfer. If the patient will need more than 1 to 2 days of treatment, a more permanent “long-line” catheter is advisable.

One special case deserves mention: direct admissions from the community to subacute care. Because of Medicare’s “3-day rule,” direct admissions come only in managed care patients (who are exempt from this rule), or patients who have had a 3-day hospital admission in the previous 30 days. Direct admissions should be medically stable and should not require immediate diagnostic or therapeutic intervention. In these cases, it is crucial that appropriate information, including reason for admission, medical history, physical examination, medications, treatments, allergies, and the like, be transmitted from the emergency department or doctor’s office. A direct dialog between the sending and receiving physician is often required. Only systems that can care for high-acuity subacute patients should consider direct admission.

Those who work in a subacute environment need to understand the crucial role played by the first 24 hours postadmission. From a clinical outcome, patient satisfaction, and a risk management perspective, the first day and night in the facility is key. Case 1 illustrates some of the perils of the hospital–subacute transfer.

Case 1: Transition of Care Issues in the First 24 Hours

An 85-year-old male retired professor is admitted with a hip fracture, hypertension, and diabetes. Here are some common issues that arise that can impact outcomes in a subacute setting:

1. 
   

   Family communication: The patient’s daughter does not know if and when her father is going to the subacute facility and does not know how to get to the subacute facility.

   
   
2. 
   

   Timing of admission: The patient is scheduled for a 2 p.m. arrival, but arrives at 6 p.m. because the hospital nurse had another sick patient and did not get the paperwork done. The patient left the hospital before dinner was served and arrived at the subacute facility after dinner was over.

   
   
3. 
   

   Avoidable complications: His blood glucose was 40 mg/dL and he was lethargic by the time his dinner arrived.

   
   
4. 
   

   Missing information:

   
   
   
   
   • The weight-bearing status is not given on the hospital referral.
     
   • The page 1 referral had a “titrate Coumadin to INR of 2.0” order but no dose and no INRs.
     
   • The discharge summary did not arrive with the patient.
     
   • The hospital was not aware that the patient took glaucoma drops and therefore these medications were not noted on the referral form.
   
   
   
   
5. 
   

   Facility issues:

   
   
   
   
   • Physical therapy had left by the time the patient arrived and nursing was not comfortable transferring the patient out of bed to the toilet.
     
   • Diapers were placed on the patient irrespective of continence status.
     
   • The room smelled because the patient was incontinent.
     
   • Pain medicine was ordered but was not delivered until the next morning.
   
   

The daughter arrives, sees her father in diapers, in pain, more confused, and the nurses unsure about his medications, and wants to send the patient back to the hospital and says she is going to write a complaint letter to the Department of Public Health.

The issues that arise in Case 1 are not unusual. Patients arrive unexpectedly, sometimes with medical issues requiring prompt attention, and the information transmitted is inadequate and sometimes contradictory. Interagency referral forms maybe done at different times than discharge summaries and can contain conflicting information.

Nursing home clinicians often manage new SNF admissions telephonically for the first 24 hours. Accurate, complete nursing assessments are important to the SNF clinician who is attempting to manage a patient he or she has never met over the phone. Nurses who work on subacute units need to work effectively with their offsite physician colleagues. An important aspect of this collaboration is judgment as to when to page the physician/APC and what information to have available. Nurses need to perform an appropriate assessment of the patient based on the clinical situation. In addition, it is important to have information on medications being given, as well as recent laboratory results.